Form Bca 13.45 - Application For Withdrawal And Final Report
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BCA 13.45
FORM
(rev. Dec. 2003)
APPLICATION FOR WITHDRAWAL
AND FINAL REPORT
Business Corporation Act
Secretary of State
Department of Business Services
501 S. Second St., Rm. 350
Springfield, IL 62756
217-782-6961
Remit payment in the form of a
check or money order payable
to Secretary of State.
Filing Fee: $25
___________________________________ File #______________________________
Approved: ___________
———— Submit in duplicate ———— Type or Print clearly in black ink ———— Do not write above this line ————
1. Corporate Name: ________________________________________________________________________________
2. State or Country of Incorporation: ___________________________________________________________________
3. Post Office Address to which the Secretary of State may mail a copy of any process served upon it against the
corporation:
______________________________________________________________________________________________
______________________________________________________________________________________________
4. No portion of the Corporation’s issued shares at this time is represented by business transacted or property located in
Illinois.
5. The Corporation surrenders its authority to transact business in Illinois.
6. The Corporation 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. (See Note 1 on
reverse.)
Date of Issuance
Number of
Entire Consideration
____________
_____________
______________
______________
______________
or Contribution
Class
Par Value
Shares Issued
Received
$_____________
$_____________
TOTAL
$_____________
(COMPLETE BOTH SIDES OF DOCUMENT)
Printed by authority of the State of Illinois. January 2015 - 1 - C 164.14
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