Form Bca-12.45/ 13.60 - Application For Reinstatement Domestic/foreign Corporation - Illinois Secretary Of State
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1APPLICATION FOR REINSTATEMENT
File #
BCA-12.45/
Form
DOMESTIC/FOREIGN CORPORATION
13.60
(Rev. August 2001)
Submit in Duplicate
BUSINESS CORPORATION ACT
Jesse White
This space for use by Secretary of State
Date
Secretary of State
Department of Business Services
Springfield, IL 62756
Filing Fee
$ 100.00
(Note 1)
Domestic: (217) 782-5797
(217) 785-5782
Foreign:
(217) 782-1837
Approved:
See Note 1 for
payment instructions
1.
(a) Corporate name as of the date of issuance of the certificate of dissolution or revocation:
________________________________________________________________________________
________________________________________________________________________________
(note 2)
(b) Corporate name if changed
: ___________________________________________________
________________________________________________________________________________
(c) If a foreign corporation having a certificate of authority under an assumed corporate name restriction, the
(note 3)
assumed corporate name
: ____________________________________________________
________________________________________________________________________________
2.
State of incorporation: __________________________________________________________________
3.
Date that the certificate of dissolution or revocation was issued: _________________________________
4.
Name and address of the Illinois registered agent and the Illinois registered office, upon reinstatement:
(note 4)
NOTICE! Completion of item #4 does not constitute a registered agent or office change.
Registered Agent
____________________________________________________________
First Name
Middle Name
Last Name
Registered Office
____________________________________________________________
Number
Street
Suite # (A P.O. Box alone is not acceptable)
____________________________________________________________
City
ZIP Code
County
5.
This application is accompanied by all delinquent report forms together with the filing fees, franchise taxes,
(note 1)
license fee and penalties required.
6.
The undersigned corporation has caused this statement to be signed by its duly authorized officers, each of
whom affirms, under penalties of perjury, that the facts stated herein are true. If there are no duly authorized
officers, then the persons designated by Section 1.10(b) (2) must sign below and type or print name and title.
(All signatures must be in BLACK INK.)
Dated ___________________________________
________________________________________
(Month, Day & Year)
(Exact Name of Corporation)
By _______________________________________
(Any Authorized Officer’s Signature)
_______________________________________
(Print name and title)
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