Free Petition for Refund - Illinois

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Form July 2003

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LLC-5.48

Illinois Limited Liability Company Act

FILE #
This space for use by Secretary of State.

Secretary of State Jesse White Department of Business Services Limited Liability Division 501 S. Second St., Rm. 351 Springfield, IL 62756 217-524-8008 www.cyberdriveillinois.com Payment may be made by business firm check payable to Secretary of State. If check is returned for any reason this filing will be void.

Petition for Refund
SUBMIT IN DUPLICATE
Must be typewritten. This space for use by Secretary of State.

Date: Filing Fee: $15 Approved:

1. 2. 3. 4.

Limited Liability Company Name: __________________________________________________________________ File Number assigned by the Secretary of State: _____________________________________________________ State of Organization: __________________________________________________________________________ Amount of Claim: _____________________________________________________________________________ No refund shall be made from an overpayment of less than $200. Any amount to be refunded shall be reduced by $200. Details of Transaction and all facts upon which the petitioner relies: (If there is not sufficient space to cover this point, attach additional sheets of this size.)

5.

6.

I affirm, under the penalties of perjury, having the authority to sign hereto, that this penalty form is to the best of my knowledge and belief, true, correct and complete.

Dated________________________________, ____________.
Month & Day Year

______________________________________
Signature

______________________________________
Name and Title (type or print)

______________________________________
If applicant is a Company or other Entity, state Name of Company and indicate whether it is a member or manager of the LLC.

Printed by authority of the State of Illinois. April 2007 -- 500 -- LLC 35.1