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STATE OF ILLINOIS FOREIGN CORPORATION ANNUAL REPORT
PLEASE TYPE OR PRINT CLEARLY IN BLACK INK
CORPORATION FILE #: __________________
NOTE: A change in the Registered Agent and/or Registered Office may only be effected by filing Form BCA-5.10/5.20. If there have been any changes in items 6 or 7a, Form BCA-14.30 must be completed and submitted in the same envelope. 1. Corporate Name: Registered Agent: Registered Office: City, IL, ZIP Code:
County:
2. 3a. 3b. 4.
Principal Address of Corporation: _______________________________________________________________________________________
Street City State ZIP Code
State or Country of Incorporation: __________________________________________ Date Qualified To Do Business in Illinois: __________________________________________
Month Day Year
Names and Addresses of Officers and Directors: NOTE: The names and addresses of ALL officers and directors must be entered in this item. NAME NUMBER & STREET CITY STATE ZIP
OFFICE President Secretary Treasurer Director Director Director 5. 6.
If 51% or more of stock is owned by a minority or female, please check appropriate box: Number of shares authorized and issued (as of SERIES PAR VALUE ):
Minority Owned
Female Owned
CLASS
NUMBER AUTHORIZED
NUMBER ISSUED
IMPORTANT: If the amount in item 6 or 7a differs from the Secretary of State's records, Form BCA 14.30 must be completed. . 7a. Amount of Paid-in Capital (as of ______________________ ): $ __________________________ 7b. 8. Paid-in Capital on record with Secretary of State: $ _____________________________________ By ____________________________________________________________________________
Any Authorized Officer's Signature Title Date
(Paid-in Capital reflects the sum of the Stated Capital and Paid-in surplus accounts.)
Under the penalty of perjury and as an authorized officer, I declare that this annual report, pursuant to provisions of the Business Corporation Act, has been examined by me and is, to the best of my knowledge and belief, true, correct and complete.
Item 8 Must Be Signed.
RETURN TO: Jesse White, Secretary of State Department of Business Services · 501 S. Second St. · Springfield, IL 62756 217-782-7808 · www.cyberdriveillinois.com
Please Complete Reverse Side of This Report
PRESIDENT SECRETARY IF THE ABOVE OFFICERS' NAMES AND ADDRESSES ARE MISSING OR HAVE CHANGED, ENTER ONLY THE ADDITIONS OR CORRECTIONS BELOW. PRESIDENT SECRETARY
Name Name Street Address Street Address City City State State
File #
ZIP Code ZIP Code
Printed by authority of the State of Illinois. October 2008 -- 2.5M -- C 288.5
(Item 9 OR 10a OR 10b, whichever is applicable, MUST be completed.) 9. Amounts stated in parts (a) through (d) below are given for the 12-month period ending __________________________________________ , _____________ . Day Month Year
Value of the property (gross assets): (a) owned by the corporation, wherever located: ....................................................................................................................... (a) $ (b) of the corporation located within the State of Illinois: ............................................................................................................ (b) $ Gross amount of business transacted by the corporation: (c) everywhere for the above period: .......................................................................................................................................... (c) $ (d) at or from places of business in Illinois for the above period: ............................................................................................... (d) $
ALLOCATION FACTOR =
b+d a+c
=
.
6 decimal places
Enter this figure on line 11b below.
10a. ALL property of the Corporation is located in Illinois and ALL business of the Corporation is transacted at or from places of business in Illinois. 10b. The Corporation elects to pay franchise tax on the basis of 100% of its total Paid-in Capital.
ALLOCATION FACTOR = 1.00000 (Enter this figure on line 11b below.)
STOP: Item 9 or 10 must be completed before continuing to Item 11.
11. ANNUAL FRANCHISE TAX AND FEES
11a. TOTAL PAID-IN CAPITAL (Enter amount from Item 7a; if late, enter the greater of 7a or 7b.) ...................................................................... a. 11b. ALLOCATION FACTOR (Enter from Item 9 or Item 10.) ....................................... b. 11c. ILLINOIS CAPITAL (Multiply line 11a by line 11b.) ................................................ c.
11d1. Multiply line 11c by .001 (Round to nearest cent.) ................................................. d1. 11d2. ANNUAL FRANCHISE TAX (Enter amount from line d1, but not less than $25.) .................................................. d2.
11e1. If Annual Report is late, multiply line d2 by .10 ...................................................... e1. 11e2. If Annual Franchise Tax is late, multiply line d2 by .02 for each month e2. late or part thereof (minimum $1) ........................................................................................................ 11e3. INTEREST & PENALTIES (Add lines e1 and e2.) ................................................................................................. e3. 11f. ANNUAL REPORT FILING FEE ($75) ................................................................................................................... 11f.
11g. TOTAL ANNUAL FRANCHISE TAX, FEES, INTEREST, PENALTIES DUE (Add line d2 + line e3 + line f.) ................................................................................................................................ 11g. MAKE CHECKS PAYABLE TO ILLINOIS SECRETARY OF STATE. (Place corporate file number on check.)
IMPORTANT If there have been changes in Items 6 or 7, Form BCA 14.30 must be executed and submitted with this Annual Report in the same envelope.
Printed by authority of the State of Illinois. October 2008 -- 2.5M -- C 288.5
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+ 75.00