FORM BCA 14.05 (rev. Oct. 2014) DOMESTIC CORPORATION ANNUAL REPORT Business Corporation Act Secretary of State Department of Business Services 501 S. Second St., Rm. 350 Springfield, IL 62756 217-782-7808 www.cyberdriveillinois.com Payment must be made by check or money order payable to Secretary of State. File Prior To: _________________________ Year: _________________ File #: _______________________ Approved: ___________ Note: A change in the Registered Agent and/or Registered Office may only be affected by filing Form BCA-5.10/5.20. 1. Corporate Name: Registered Agent: Registered Office: City, IL, ZIP Code: Street County: City State ZIP Code 2. 3. 4. Principal Address of Corporation: ____________________________________________________________________________ Date Incorporated:__________________________________ Month Day Year Names and Addresses of Officers and Directors: NOTE: The names and addresses of ALL officers and directors must be entered in this item or on an additional sheet. OFFICE President Secretary Treasurer Director Director Director NAME NUMBER& STREET CITY STATE ZIP 5. 6. If 51% or more of stock is owned by a minority or female, please check the appropriate box: n Minority Owned Number of shares authorized and issued (as of ________________________): CLASS SERIES PAR VALUE NUMBER AUTHORIZED n Female Owned NUMBER ISSUED IMPORTANT: If the amount in item 6 or 7a differs from the Secretary of State's records, form BCA 14.30 must be completed. 7a. 7b. Amount of Paid-in Capital (as of ________________________________ ): $ ________________________________________ Paid-in Capital on record with Secretary of State: $ _____________________________________________________________ (Paid-in Capital reflects the sum of the Stated Capital and Paid-in surplus accounts.) Under the penalty of perjury and as an authorized officer, I declare that this annual report, 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. Item 8 Must Be Signed. 8. By: ___________________________________________________________________________________________________ Any Authorized Officer's Signature Title Date Please Complete Reverse Side of This Report Printed by authority of the State of Illinois. March 2016 -- 1.5M -- C 289.11 American LegalNet, Inc. www.FormsWorkFlow.com Item 9 OR 10a OR 10b, whichever is applicable, MUST be completed.) 9. Amounts stated in parts (a) through (d) below are given for the 12-month period ending ________________________________________ , ________________. Day Month Year Value of property (gross assets): (a) owned by the corporation, wherever located: ............................................................. (a) (b) of the corporation located within the State of Illinois:.................................................. (b) Gross amount of business transacted by the corporation: (c) everywhere for the above period: ............................................................................... (c) (d) at or from places of business in Illinois for the above period: ..................................... (d) $ ______________________ $ ______________________ $ ______________________ $ ______________________ ALLOCATION FACTOR = b+d a+c = = ____________________ Enter this figure on line 11b below. 6 decimal places . 10a. ALL property of the Corporation is located in Illinois and ALL business of the Corporation is transacted at or from places of business in Illinois. 10b. The Corporation elects to pay franchise tax on the basis of 100% of its total Paid-in Capital. ALLOCATIONFACTOR = 1.00000 (Enter this figure on line 11b below.) STOP: Item 9 or 10 must be completed before continuing to Item 11. 11. 11a. ANNUAL FRANCHISE TAX AND FEES TOTAL PAID-IN CAPITAL (Enter amount from Item 7a; a. if late, enter the greater of 7a or 7b.) ....................................................................._________________________ b. ALLOCATION FACTOR (Enter from Item 9 or Item 10.)........................................_________________________ c. ILLINOIS CAPITAL (Multiply line 11a by line 11b.).................................................________________________ 11b. 11c. 11d1. Multiply line 11c by .001 (Round to nearest cent.) ................................................. d1 11d2. ANNUAL FRANCHISE TAX (Enter amount from line d1, but not less than $25)................................................... d2. e1. 11e1. If Annual Report is late, multiply line d2 by .10 ......................................................________________________ 11e2. If Annual Franchise Tax is late, multiply line d2 by .02 for each month e2. late or part thereof (minimum $1)...........................................................................________________________ 11e3. INTEREST & PENALTIES (Add lines e1 and e2.) ................................................................................................. e3. 11f. 11g. ANNUAL REPORT FILING FEE ($75) .................................................................................................................. 11f. TOTAL ANNUAL FRANCHISE TAX, FEES, INTEREST, PENALTIES DUE (Add line d2 + line e3 + line f.) ...............................................................................................................................11g. $75.00 MAKE CHECKS PAYABLE TO ILLINOIS SECRETARY OF STATE. (Place corporate file number on check.) IMPORTANT: If there have been changes in Items 6 or 7, Form BCA 14.30 must be executed and submitted with this Annual Report in the same envelope. American LegalNet, Inc. www.FormsWorkFlow.com