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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
This space for use by Secretary of State.
File #: SUBMIT IN DUPLICATE
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
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