Form Llc-50.15 - Limited Liability Company Act - Illinois Secretary Of State
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Illinois
LLC-50.15
This space for use by
Form
Secretary of State
Limited Liability Company Act
December 2003
PENALTY – RETURN TO GOOD STANDING
Jesse White
Secretary of State
Department of Business Services
Limited Liability Company Division
Submit in Duplicate
Room 351, Howlett Building
Must be typewritten
Springfield, IL 62756
This space for use by Secretary of State
Date
Payment must be made by certified
check, cashier's check, Illinois
Assigned File #
attorney's check, Illinois C.P.A.'s check
Filing Fee
$
or money order, payable to "Secretary
Approved:
of State."
1. Limited Liability Company name: __________________________________________________________________
____________________________________________________________________________________________
2. File number assigned by the Secretary of State: ______________________________________________________
3. The registered agent's name and registered office address is:
Registered agent:
________________________________________________________________________
First Name
Middle Initial
Last Name
Registered Office:
________________________________________________________________________
Number
Street
Suite #
(P.O. Box and
c/o are unacceptable)
________________________________________________________________________
City
ZIP Code
County
4. The penalties applicable to return the limited liability company to good standing are as follows: (Check and complete
where appropriate)
a)
$ _______ Failure to file the annual report and pay the requisite fee prior to the first day of the anniversary month.
b)
$ _______ Failure to appoint and maintain a registered agent in Illinois as required.
Total penalty amount (a and b) is $ _________________
5. I affirm, under penalties of perjury, having authority to sign hereto, that this penalty form is to the best of my knowledge
and belief, true, correct and complete.
Dated _______________________________ , ___________ .
(Month & Day)
(Year)
_______________________________________________
(Signature)
_______________________________________________
(Type or print Name and Title)
_______________________________________________
(If applicant is a company or other entity, state name of company
and indicate whether it is a member or manager of the LLC.)
LLC-7.5
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