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, 1,640 Characters
Page Size: Letter (8 1/2" x 11")

Download Petition for Refund or Review ( 327.9 kB)

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


Petition for Refund or Review
This space for use by Secretary of State.

This space for use by Secretary of State.

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


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