Form Llc-5.48 - Petition For Refund
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PETITION
LLC-5.48
This space for use by
Form
Secretary of State
for
November 2006
REFUND
Secretary of State Jesse White
Department of Business Services
Limited Liability Division
SUBMIT IN DUPLICATE
Room 351 Howlett Building
Must be typewritten
501 S. Second St.
Springfield, IL 62756
This space for use by Secretary of State
Telephone (217) 524-8008
Date
Assigned File #
Remit payment in check or money order
Filing Fee
$15.00
payable to "Secretary of State"
Approved:
1.
Limited Liability Company Name: _________________________________________________________
2.
File number assigned by the Secretary of State: ____________________________________________ _
3.
State of Organization: __________________________________________________________________
4.
Amount of Claim: _____________________________________________________________________ _
No refund shall be made from an overpayment of less than $200.
Any amount to be refunded shall be reduced by $200.
5.
Details of the transaction and all facts upon which the petitioner relies:
(If there is not sufficient space to cover this point, attach a sheet of white 8 1/2 X 11 paper.)
6.
I affirm, under the penalties of perjury, having the authority to sign hereto, that this penalty form is to the
best of my knowledge and belief, true, correct and complete.
Dated________________________________, ____________.
(Month & Day)
(Year)
______________________________________
(Signature)
______________________________________
(Type or print Name and Title)
______________________________________
(If applicant is a company or other entity, state name of company and
indicate whether it is a member or manager of the LLC.)
Printed by authority of the State of Illinois. November 2006 — 1M — LLC-35.1
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