Form Bca 9.05 - Statement Of Cancellation Of Non Reissuable Shares

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BCA 9.05
FORM
(rev. Dec. 2003)
STATEMENT OF CANCELLATION
OF NON-REISSUABLE SHARES
Business Corporation Act
Secretary of State
Department of Business Services
501S. 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: $5
____________________________________ File #_____________________________
Approved: ____________
———— Submit in duplicate ———— Type or Print clearly in black ink ———— Do not write above this line ————
1. Corporate Name: ________________________________________________________________________________
2. The Corporation has acquired and cancelled its own shares, and the Articles of Incorporation prohibit the re-issuance
of such shares.
3. Number of shares cancelled and redemption or purchase price:
Class
Series
Par Value
Number of Shares
Redemption or
Date of
Cancelled
Purchase Price
Cancellation
____________
_____________
______________
______________
______________
______________
BEFORE CANCELLATION
AFTER CANCELLATION
Class
Series
Par
Number
Class
Series
Par
Number
4. Number of
authorized
shares:
5. Number of
issued shares:
6. Paid-in capital:
$_________________________
$_________________________
7. 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. All signatures must be in BLACK INK.
Dated _______________________________ , _____
________________________________________________
Month Day
Year
Exact Name of Corporation
______________________________________
Any Authorized Officer’s Signature
______________________________________
Name and Title (type or print)
NOTE: This form is applicable only where the Articles of Incorporation provide that shares redeemed or purchased shall be
cancelled and shall not be re-issued. Upon such redemption and cancellation of shares, the paid-in capital of the Corporation
is deemed to be reduced by that part of the paid-in capital which was represented by the shares so cancelled. The filing of
this statement operates as an amendment to the Articles of Incorporation and reduces the number of shares of the class so
redeemed which the Corporation is authorized to issue by the number of shares so redeemed and cancelled.
Printed by authority of the State of Illinois. January 2015 - 1 - C 150.12

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