Form Bca 14.05 - Domestic Corporation Annual Report - 2014

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BCA 14.05
FORM
(rev. Oct. 2014)
DOMESTIC CORPORATION
ANNUAL REPORT
Business Corporation Act
Secretary of State
Department of Business Services
501 S. Second St., Rm. 350
Springfield, IL 62756
217-782-7808
Payment must be made by check or money
order payable to Secretary of State.
File Prior To: _________________________ Year: _________________ File #: _______________________ Approved: ___________
Note: A change in the Registered Agent and/or Registered Office may only be affected by filing Form BCA-5.10/5.20.
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:__________________________________
r
Month
Day
Yea
4.
Names and Addresses of Officers and Directors:
NOTE: The names and addresses of ALL officers and directors must be entered in this item or on an additional sheet.
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 the appropriate box:
Minority Owned
Female Owned
6.
Number of shares authorized and issued (as of ________________________):
CLASS
SERIES
PAR VALUE
NUMBER AUTHORIZED
NUMBER ISSUED
IMPORTANT: If the amount in item 6 or 7a differs from the Secretary of State’s records, form BCA 14.30 must be completed.
7a.
Amount of Paid-in Capital (as of ________________________________ ): $ ________________________________________
7b.
Paid-in Capital on record with Secretary of State: $ _____________________________________________________________
(Paid-in Capital reflects the sum of the Stated Capital and Paid-in surplus accounts.)
Under the penalty of perjury and as an authorized officer, I declare that this annual report, pursuant to provisions of the Business Corporation Act, has been
examined by me and is, to the best of my knowledge and belief, true, correct and complete.
Item 8 Must Be Signed.
8.
By: ___________________________________________________________________________________________________
Any Authorized Officer’s Signature
Title
Date
Please Complete Reverse Side of This Report
Printed by authority of the State of Illinois. January 2015 — 1 — C 289.11

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