Form NFP10415/20 (Rev. Aug. 2014) APPLICATION TO ADOPT, CHANGE OR CANCEL an ASSUMED CORPORATE NAME General Not For Profit Corporation Act Secretary of State Department of Business Services 501 S. Second St., Rm. 350 Springfield, IL 62756 217-782-9520 217-782-6961 www.cyberdriveillinois.com Payment must be made by check or money order payable to Secretary of State. 1. Corporate Name: ________________________________________________________________________________ -------- Submit in duplicate -------- Type or Print clearly in black ink -------- Do not write above this line -------- Filing fee $ _________________________ File # ___________________________ Approved: _________________ 2. State or Country of Incorporation: ___________________________________________________________________ _________________________________________________. Month & Day Year 3. Date Incorporated (if an Illinois corporation) or Date Authorized to Transact Business in Illinois (if a foreign corporation): 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 month in the next year evenly divisible by five. Month & Day Year ______________________________________________________________________________________________ of State until _______________________________________________, the first day of the corporation's anniversary 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 Year Any Authorized Officer's Signature Name and Title (type or print) ______________________________________________________________________________________________ ______________________________________ ______________________________________ ________________________________________________ Exact Name of Corporation 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 to change an assumed name is $5. The fee for cancelling an assumed corporate name is $5. Printed by authority of the State of Illinois. January 2015 -- 1 -- C 211.9 American LegalNet, Inc. www.FormsWorkFlow.com