Form Bca-14.01 - Statement Of Election To Establish An Extended Filing Month Page 3
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4Form BCA 14.05-I
STATE OF ILLINOIS
YEAR OF _______
File #
DOMESTIC/FOREIGN CORPORATION
INTERIM ANNUAL REPORT
Please Type or Print Clearly in Black Ink
1.
CORPORATE NAME
REGISTERED AGENT
REGISTERED OFFICE
CITY, IL, ZIP CODE
2.
(a) Date of Incorporated/Qualified:
________________
(b) State or Country of Incorporation:
________________
3.
(a) Give complete address of principal office,
if other than above.
_____________________________________________
_____________________________________________
3.
(b) FEIN No.: ____________________________________
4.
Names and addresses of the officers and directors (If officers are directors, so state.):
Name
Number & Street
City
State
ZIP
President
Secretary
Treasurer
Director
Director
Director
5.
Type of business actually conducted in Illinois: _______________________________________________
6.
Authorized and issued shares as of ____________________ :
(Date)
Class
Series
Par Value
Number Authorized
Number issued
7.
(a) Paid-in capital as of ___________________ :
(b) Paid-in Capital as of ________________________ ,
(Date)
(Date)
PAID-IN CAPITAL $ __________________
on record with the Secretary of State:
(
TOTAL $ _____________________________
"Paid-in Capital" replaces the terms "Stated Capital" and
"Paid-in Surplus." It does not include Retained Earnings.)
(x)
Previous Allocation Factor: ____________________
ITEM 8 MUST BE SIGNED
8.
By: ___________________________________________________________________________________
(Authorized Officers's Signature)
(Title)
(Date)
Under penalty of perjury and as an authorized officer, I declare that this annual report and, if applicable, the statement of change of
registered agent and/or office, 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.
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