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BCA-5.25
FORM
(rev. Dec. 2014)
AFFIDAVIT OF COMPLIANCE
FOR SERVICE ON SECRETARY OF STATE
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: $10
File #: ___________________________
Approved: ______________________
________ Submit in duplicate ________ Type or Print clearly in black ink ________ Do not write above this line ________
1.
Title and Number of Case:
________________________________
first named plaintiff
Number: _______________
V.
________________________________
first named defendant
2.
Name of corporation being served: ____________________________________________________________
3.
Title of court in which an action, suit or proceeding has been commenced: _____________________________
4.
Title of instrument being served: ______________________________________________________________
5.
Basis for service on the Secretary of State: (check and complete appropriate box)
a. ❏
The corporation’s registered agent cannot with reasonable diligence be found at the registered office of
record in Illinois.
b. ❏
The corporation has failed to appoint and maintain a registered agent in Illinois.
c. ❏
The corporation was dissolved on ___________________________ , _________ ; the conditions
Month Day
Year
of paragraphs (a) or (b) above exist; and the action, suit or proceeding has been instituted against or
has affected the corporation within five (5) years thereafter.
d. ❏
The corporation’s authority to transact business in Illinois has been withdrawn/revoked (circle one) on
________________________ , ___________ .
Month Day
Year
e. ❏
The corporation is a foreign corporation that has transacted business in Illinois without procuring authority,
contrary to the provisions of the Business Corporation Act of 1983.
6.
Address to which the undersigned will cause a copy of the attached process, notice or demand to be sent by certified
or registered mail:__________________________________________________________________________
7.
The undersigned affirms, under penalties of perjury, that the facts stated herein are true, correct and complete.
_________________________________________
_____________________________
___________
Signature of Affiant
Month Day
Year
__________________________________________
( )
Telephone Number
Return to (please type or print clearly):
____________________________________
Name
____________________________________
Street
____________________________________
City/Town
State
Zip
Printed by authority of the State of Illinois. January 2015 — 1 — C 213.11
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