Free Petition for Refund or Review - Illinois



Download File ( 327.9 kB)
Print 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. Reset 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 b

Print
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.

Reset

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

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")
URL

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