Form Bca-14.35 - Report Following Merger Or Consolidation

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BCA-14.35
FORM
(rev. Dec. 2014)
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Report Following Merger
or Consolidation
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.
File #: ___________________________
Approved: ______________________
Franchise Tax: $_________ Filing Fee: $5
Penalty: $_________ Interest: $_________ Total: $_________
________ Type or Print clearly in black ink ________ Do not write above this line ________
1. Corporate Name: ________________________________________________________________________________
2. State or Country of Incorporation: ___________________________________________________________________
3. Issued shares of each corporation party to the merger prior to the merger:
Corporation
Class
Series
Par Value
Number of Shares
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
4. Paid-in Capital of each corporation party to the merger prior to the merger:
Corporation
Paid-in Capital
________________________________________________________________________________________________
$
________________________________________________________________________________________________
$
________________________________________________________________________________________________
$
________________________________________________________________________________________________
$
________________________________________________________________________________________________
5. Description of merger:
(Include effective date and brief explanation of the conversion as stated in the plan of merger.)
6. Issued shares after merger:
Class
Series
Par Value
Number of Shares
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
7. Paid-in Capital of the surviving or new corporation: $ ________________
("Paid-in Capital" replaces the terms Stated Capital and Paid-in Surplus and is equal to the total of these accounts.)
ITEM 8 MUST BE SIGNED
8. 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
______________________________________
Any Authorized Officer’s Signature
______________________________________
Name and Title (type or print)
Printed by authority of the State of Illinois. October 2015— 1 — C 243.5

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