Free Petition for Refund or Review - Illinois


File Size: 327.9 kB
Pages: 1
Date: May 12, 2006
File Format: PDF
State: Illinois
Category: Corporations
Author: Illinois Secretary of State Business Services
Word Count: 212 Words, 1,643 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.cyberdriveillinois.com/publications/pdf_publications/bca117.pdf

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Form BCA-1.17
(Rev. Jan. 2003) Secretary of State Department of Business Services Springfield, IL 62756 217-785-2237 or 217-785-6033 www.cyberdriveillinois.com Payment must be made by check or money order payable to Secretary of State.

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Petition for Refund or Review
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File #: SUBMIT IN DUPLICATE
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Date: Filing Fee: $5 Approved:

11. Corporate Name: _______________________________________________________________________________ 12. State or Country of Incorporation: __________________________________________________________________ 13. Nature of Claim: (Mark an "X" in one box only.) Refund Adjustment of Assessment

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. April 2006 -- 5M -- C 198.8