Free Application to Adopt, Change or Cancel an Assumed Name - Illinois

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Form NFP 104.15/20
(Rev. Jan. 2003) Secretary of State Jesse White Department of Business Services 501 S. Second St., Rm. 350 Springfield, IL 62756 217-782-9520 www.cyberdriveillinois.com Remit payment in the form of a check or money order payable to Secretary of State.

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Application to Adopt, Change or Cancel an Assumed Corporate Name
Under the General Not for Profit, Corporation Act
This space for use by Secretary of State.

FILE #:
SUBMIT IN DUPLICATE This space for use by Secretary of State. Date: Filing Fee: $ (See Note Below) Approved:

1. Corporate Name: ________________________________________________________________________________ 2. State or Country of Incorporation: ___________________________________________________________________ 3. Date Incorporated (if an Illinois corporation) or Date Authorized to Transact Business in Illinois (if a foreign corporation): _____________________________________, ___________.
Month & Day Year

Complete No. 4 and No. 5 if adopting or changing an assumed corporate name. 4. Corporation intends to adopt and to transact business under the Assumed Corporate Name of: ______________________________________________________________________________________________ 5. The right to use the Assumed Corporate Name shall be effective from the date this application is filed by the Secretary of State until ____________________________________, __________, the first day of the corporation's anniversary
Month & Day Year

month in the next year evenly divisible by five. Complete No. 6 if changing or cancelling an assumed corporate name. 6. Corporation intends to cease transacting business under the Assumed Corporate Name of: ______________________________________________________________________________________________ 7. 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)

NOTE: · The filing fee to adopt an assumed corporate name is $150 if the current year ends with a 0 or 5; $120 if the current year ends with a 1 or 6; $90 if the current year ends with a 2 or 7; $60 if the current year ends with a 3 or 8; or $30 if the current year ends with a 4 or 9. · The fee for cancelling an assumed corporate name is $5. · The fee to change an assumed corporate name is $25.
Printed by authority of the State of Illinois. April 2007 -- 1M -- C 211.6