Form Llc-50.1 Annual Report - Illinois Limited Liability Company Act
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1LLC-50.1
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Illinois
FILE #
Form
Limited Liability Company Act
Due prior to:
May 2012
Annual Report
Secretary of State
This space for use by Secretary of State.
Department of Business Services
Limited Liability Division
Type or Print Clearly.
501 S. Second St., Rm. 351
This space for use by Secretary of State.
Springfield, IL 62756
Filing Fee: $250
217-524-8008
Series Fee, if required:
Penalty:
Payment may be made by check
Total:
payable to Secretary of State. If
Approved:
check is returned for any reason this
filing will be void.
1. Limited Liability Company Name:____________________________________________________________________
Registered Agent:________________________________________________________________________________
Registered Office: _____________________________________________________________IL_________________
Number
Street
Suite
City
Zip
2. State or Country of Organization: ________________________ Date Organized in or Admitted to Illinois: _____________
3. Address of Principal Place of Business: (P.O. Box alone is unacceptable.)
_______________________________________________________________________________________________
Number
Street
Suite
City, State
Zip
4. Names and Addresses of Managers or Members:
Select One:
______________________________________________________________________________________________
Name
Number & Street
City, State
Zip
MGR/MBR
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
5. Entity managers/members affirm their current existence.
6. Changes to the registered agent and/or registered office must be submitted on Form LLC-1.36/1.37.
7. 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: ___________________________, ______________
A late filing penalty of $300 will
Month/Day
Year
apply if this report is not filed within
60 days after the due date.
________________________________________________
Signature
________________________________________________
Name and Title (type or print)
________________________________________________
If applicant is a company or other entity, state Name of Company
and whether a member or manager of the LLC.
Printed by authority of the State of Illinois. October 2014 — 1 — LLC 23.11
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