Form Bca 14.05 - Domestic Corporation Annual Report - Illinois Secretary Of State

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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.

Corporate Name:

Registered Agent:

Registered Office:

City, IL, ZIP Code:

County:

Principal Address of Corporation: ____________________________________________________________________________

Street

City

State

ZIP Code

Date Incorporated:__________________________________

Month

Day

Yea

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

n n

If 51% or more of stock is owned by a minority or female, please check the appropriate box:

Minority Owned

Female Owned

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.

By: ___________________________________________________________________________________________________

Any Authorized Officer’s Signature

Title

Date

Please Complete Reverse Side of This Report

Printed by authority of the State of Illinois. March 2016 — 1.5M — C 289.11