Form Bca-1.17 - Petition For Refund Or Review

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BCA-1.17
FORM
(rev. Dec. 2014)
Petition for Refund or Review
Business Corporation Act
Department of Business Services
501 S. Second St., Rm. 350
Springfield, IL 62756
217-782-6961
Payment must be made by check or money
order payable to Secretary of State.
Filing Fee: $5
File #: ___________________________
Approved: ______________________
________ Submit in duplicate ________ Type or Print clearly in black ink ________ Do not write above this line ________
11. Corporate Name: _______________________________________________________________________________
12. State or Country of Incorporation: __________________________________________________________________
13. Nature of Claim:
Refund
Adjustment of Assessment
(Mark an “X” in one box only.)
14. Amount of Claim: $________________________________
• No refund will be made from an overpayment of less than $200.
• Any amount to be refunded will be reduced by $200.
• The $200 restrictions DO NOT apply to adjustments of assessments.
15. Reason for Claim and Facts Relied Upon:
(For more space, use reverse side or attach additional sheets of this size.)
16. The undersigned corporation has caused this statement to be signed by a duly authorized officer who affirms, under
penalties of perjury, that the facts stated herein are true and correct.
Dated _______________________________ , _____
________________________________________________
Month Day
Year
Exact Name of Corporation
by
______________________________________
Any Authorized Officer’s Signature
______________________________________
Name and Title (type or print)
Printed by authority of the State of Illinois. January 2015 — 1 — C 198.9

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