Form Bca-13.45 - Application For Withdrawal And Final Report
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BCA-13.45
APPLICATION FOR
Form
WITHDRAWAL AND FINAL REPORT
File #
(Rev. Jan. 2003)
Jesse White
SUBMIT IN DUPLICATE
Secretary of State
Department of Business Services
This space for use by
Springfield, IL 62756
Secretary of State
Date
Telephone (217) 782-6961
.com
License Fee
$
Franchise Tax
$
Filing Fee
$ 25.00
Remit payment in check or money
Penalty
$
order, payable to "Secretary of
Interest
$
State."
Approved:
1.
CORPORATE NAME: __________________________________________________________________
2.
STATE OR COUNTRY OF INCORPORATION: ______________________________________________
3.
Post office address to which may be mailed a copy of any process against the corporation that may be served
on the Secretary of State:
____________________________________________________________________________________
____________________________________________________________________________________
4.
No portion of its issued shares at this time is represented by business transacted or property located in this
State.
5.
It surrenders its authority to transact business in Illinois.
6.
It revokes the authority of its registered agent in Illinois to accept service of process, and hereby consents that
service of process in any suit, action or proceeding based upon any cause of action arising in this State during
the time this corporation was licensed to transact business in this State may hereafter be made on such
corporation by service thereof upon the Secretary of State.
(COMPLETE ONLY WHEN APPLICABLE)
7.
(a)
List all issuances of shares not previously reported to the Secretary of State (including shares issued for cash or
other property, share dividends, share splits, share exchanges pursuant to Section 11.10, and shares to effect an
exchange or reclassification of issued shares) and give the value of the entire consideration received therefor, less
expenses; list any amounts added or transferred to paid-in capital, without the issuance of shares.
Date of Issuance
Number of
Entire Consideration
or Contribution
Class
Par Value
Shares Issued
Received
$
$ __________________
TOTAL
$
(b)
List all cancellations of shares not previously reported to the Secretary of State, and give the cost.
Date of Cancellation
Class
Number of Shares Cancelled
Cost
$
$ __________________
TOTAL
$
(COMPLETE BOTH SIDES OF REPORT)
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