Illinois Domestic Corporation Annual Report - Illinois Secretary Of State - 2011
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STATE OF ILLINOIS
YEAR OF:
CORPORATION
DOMESTIC CORPORATION ANNUAL REPORT
File Prior to:
File #: ________________
Note: A change in the Registered Agent and/or Registered Office may only be effected by filing Form BCA-5.10/5.20. If there have
been any changes in items 6 or 7a, Form BCA-14.30 must be completed and submitted in the same envelope.
1.
Corporate Name:
Registered Agent:
Registered Office:
City, IL, ZIP Code:
County:
2.
Principal Address of Corporation: ____________________________________________________________________________
Street
City
State
ZIP Code
3.
Date Incorporated:__________________________________
Month
Day
Year
4.
Names and Addresses of Officers and Directors:
NOTE: The names and addresses of ALL officers and directors must be entered in this item.
OFFICE
NAME
NUMBER & STREET
CITY
STATE
ZIP
President
Secretary
Treasurer
Director
Director
Director
■ ■
■ ■
5.
If 51% or more of stock is owned by a minority or female, please check appropriate box:
Minority Owned
Female Owned
6.
Number of shares authorized and issued (as of ________________________):
CLASS
SERIES
PAR VALUE
NUMBER AUTHORIZED
NUMBER ISSUED
President
Secretary
Treasurer
Director
Director
Director
IMPORTANT: If the amount in item 6 or 7a differs from the Secretary of Stateʼs records, form BCA 14.30 must be completed.
7a.
Amount of Paid-in Capital (as of ___________________ ): $ _________________
(Paid-in Capital reflects the sum of the Stated
Capital and Paid-in surplus accounts.)
7b.
Paid-in Capital on record with Secretary of State: $ _________________________
Under the penalty of perjury and as an authorized
8.
By: _______________________________________________________________
officer, I declare that this annual report, pursuant
Any Authorized Officerʼs Signature
Title
Date
to provisions of the Business Corporation Act, has
been examined by me and is, to the best of my
Item 8 Must Be Signed.
knowledge and belief, true, correct and complete.
RETURN TO:
Jesse White, Secretary of State
Department of Business Services • 501 S.Second St. • Springfield, IL 62756
217-782-7808 •
Please Complete Reverse Side of This Report
PRESIDENT
SECRETARY
IF THE ABOVE OFFICER’S NAMES AND ADDRESSES ARE MISSING OR HAVE
_______________
CHANGED, ENTER ONLY THE ADDITION OR CORRECTIONS BELOW.
File #
PRESI DENT _________________________________________________________________________________________________
Name
Street Address
City
State
ZIP Code
SECRETARY_________________________________________________________________________________________________
Name
Street Address
City
State
ZIP Code
Printed by authority of the State of Illinois. July 2011 — 5M — C 289.9
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