Free Report Following Merger or Consolidation - Illinois

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Form BCA-14.35
(Rev. Jan. 2003) Secretary of State Department of Business Services Springfield, IL 62756 217-782-6961 www.cyberdriveillinois.com Remit payment in the form of a check or money order, payable to Secretary of State.

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Report Following Merger or Consolidation

File #: DO NOT SEND CASH This space for use by Secretary of State Date: Franchise Tax: Filing Fee: Penalty: Interest: Approved: $ $5 $ $

1. Corporate Name: ________________________________________________________________________________ 2. State or Country of Incorporation: ___________________________________________________________________ 3. Issued shares of each corporation party to the merger prior to the merger:
Corporation Class Series Par Value Number of Shares

_________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 4. Paid-in Capital of each corporation party to the merger prior to the merger:
Corporation Paid-in Capital

_________________________________________________________________________________________________ $ _________________________________________________________________________________________________ $ _________________________________________________________________________________________________ $ _________________________________________________________________________________________________ $ _________________________________________________________________________________________________ $ _________________________________________________________________________________________________ 5. Description of merger: (Include effective date and brief explanation of the conversion as stated in the plan of merger.)

6. Issued shares after merger:
Class Series Par Value Number of Shares

_________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 7. Paid-in Capital of the surviving or new corporation: $ ________________
("Paid-in Capital" replaces the terms Stated Capital and Paid-in Surplus and is equal to the total of these accounts.)

ITEM 8 MUST BE SIGNED 8. 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 Any Authorized Officer's Signature Year

________________________________________________
Exact Name of Corporation

______________________________________ ______________________________________
Name and Title (type or print) Printed by authority of the State of Illinois. June 2006 -- 5M -- C 243.3