Jesse White
L.L.C. File Number: ________________________
Secretary of State – State of Illinois
Domestic Limited Liability Company
Filing Deadline is Prior to : _________________
Annual Report
This report must be RECEIVED in the office of the Secretary
of State prior to the anniversary date to avoid late filing penalties
$250 Filing Fee
and eventual administrative dissolution of its organization.
LLC-50.1(D)
Form
December 2003
Must be typewritten
1. Limited Liability Company name:
Registered Agent, Registered Office, City, IL, ZIP Code
Print
Reset
2. Address of the office at which the records required by Section 1-40 are to be kept is:
(Number)
(Street)
(Suite)
(City, State)
(ZIP Code)
(County)
3. Names and addresses of the managers or, if none, the members:
Name
Number & Street
City, State
ZIP Code
Select one:
MGR/MBR
4. The mgrs/mbrs, which are entities, affirm the evidence of existence on file with the Illinois Secretary of State is still intact.
5. I affirm, under penalties of perjury, having authority to sign thereto, that this annual report is to the best of my knowledge and
belief, true, correct and complete.
Dated _____________________________ , __________ .
(Date & Month)
(Year)
Payment may be made by business firm
check payable to Secretary of State. (If
check is returned for any reason this filing
(Signature)
will be nullified.)
Return to:
(Type or print Name and Title of Mgr. or Mbr.)
JESSE WHITE
SECRETARY OF STATE
(If applicant is a company or other entity, state name of company
Department of Business Services
and indicate whether it is a member or manager of the LLC.)
Limited Liability Company Division
Room 351, Howlett Building
Springfield, IL 62756
LLC-22.3