File Prior to:
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.
City, IL, ZIP Code:
Principal Address of Corporation: _______________________________________________________________________________________
Date Incorporated: __________________________________________
Names and Addresses of Officers and Directors:
NUMBER & STREET
If 51% or more of stock is owned by a minority or female, please check appropriate box: ❑ Minority Owned ❑ Female Owned
Number of shares authorized and issued (as of ):
IMPORTANT: If the amount in item 6 or 7a differs from the Secretary of State's records, Form BCA 14.30 must be completed.
Amount of Paid-in Capital (as of ______________________ ): $ __________________________
Paid-in Capital on record with Secretary of State: $ _____________________________________
Any Authorized Officer's Signature
Item 8 Must Be Signed.
IF THE ABOVE OFFICERS’ NAMES AND ADDRESSES ARE MISSING OR HAVE
CHANGED, ENTER ONLY THE ADDITIONS OR CORRECTIONS BELOW.
STATE OF ILLINOIS
DOMESTIC CORPORATION ANNUAL REPORT
PLEASE TYPE OR PRINT CLEARLY IN BLACK INK
(Paid-in Capital reflects the sum of the
Stated Capital and Paid-in surplus ac-
Under the penalty of perjury and as an authorized
officer, I declare that this annual