Illinois Domestic Corporation Annual Report - Illinois Secretary Of State - 2011 Page 2

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(Item 9 OR 10a OR 10b, whichever is applicable, MUST be completed.)

Amounts stated in parts (a) through (d) below are given for the 12-month period

ending ________________________________________ , ________________.

Day

Month

Year

Value of property (gross assets):

(a) owned by the corporation, wherever located: ............................................................. (a)

$ ______________________

(b) of the corporation located within the State of Illinois:.................................................. (b)

$ ______________________

Gross amount of business transacted by the corporation:

$ ______________________

(d) at or from places of business in Illinois for the above period: ..................................... (d)

$ ______________________

ALLOCATION FACTOR =

b + d

____________________ Enter this figure on line 11b below.

a + c

6 decimal places

■ ■

10a.

ALL property of the Corporation is located in Illinois and ALL business of the Corporation is transacted at or from places of busi-

ness in Illinois.

■ ■

10b.

The Corporation elects to pay franchise tax on the basis of 100% of its total Paid-in Capital.

ALLOCATION FACTOR = 1.00000 (Enter this figure on line 11b below.)

STOP: Item 9 or 10 must be completed before continuing to Item 11.

11.

ANNUAL FRANCHISE TAX AND FEES

11a. TOTAL PAID-IN CAPITAL (Enter amount from Item 7a;

if late, enter the greater of 7a or 7b.) ....................................................................._________________________

11b. ALLOCATION FACTOR (Enter from Item 9 or Item 10.)........................................_________________________

11c.

ILLINOIS CAPITAL (Multiply line 11a by line 11b.).................................................________________________

11d1. Multiply line 11c by .001 (Round to nearest cent.) .................................................

11d2. ANNUAL FRANCHISE TAX (Enter amount from line d1, but not less than $25)................................................... d2.

e1.

11e1. If Annual Report is late, multiply line d2 by .10 ......................................................________________________

11e2. If Annual Franchise Tax is late, multiply line d2 by .02 for each month

e2.

late or part thereof (minimum $1)...........................................................................________________________

11e3. INTEREST & PENALTIES (Add lines e1 and e2.) ................................................................................................. e3 .

$75.00

ANNUAL REPORT FILING FEE ($75) .................................................................................................................. 11f.

11f.

11g.

TOTAL ANNUAL FRANCHISE TAX, FEES, INTEREST, PENALTIES DUE

(Add line d2 + line e3 + line f.) ...............................................................................................................................

11g.

MAKE CHECKS PAYABLE TO ILLINOIS SECRETARY OF STATE.

(Place corporate file number on check.)

IMPORTANT:

If there have been changes in Items 6 or 7, Form BCA 14.30 must be executed

and submitted with this Annual Report in the same envelope.

Printed by authority of the State of Illinois. July 2011 — 5M — C 289.9