FORM NFP 114.05 (rev. Oct. 2014) DOMESTIC/FOREIGN CORPORATION ANNUAL REPORT General Not for Profit Corporation Act Secretary of State Department of Business Services 501 S. Second St., Rm 350 Springfield, IL 62756 217-782-7808 www.cyberdriveillinois.com Filing Fee: $10 (if late, add $3 penalty fee.) Year: _________________ File #:_______________________ Approved: ___________ Note: A change in the Registered Agent and/or Registered Office may only be effected by filing Form NFP-105.10/105.20. Payment must be made by check or money order payable to Secretary of State. 1. 2. 3a. 4. Corporation Name: _____________________________________________________________________________ City, IL, ZIP, County: ____________________________________________________________________________ Date of Incorporation/Qualification:___________________ NAME President Secretary Treasurer Director Director Director Registered Agent: ______________________________________________________________________________ 3b. Registered Office: ______________________________________________________________________________ Names and Addresses of Corporation's Officers and Directors: OFFICE State of Incorporation: ____________________ CITY STATE ZIP NUMBER & STREET NOTE: List all officers and directors above or on an additional sheet. Illinois corporations must have three directors. 5. 6. Brief statement of type of business the corporation is conducting: Is this corporation a Condominium Association as established under the Condominium Property Act? (check one) I No I Yes ITEM 6 MUST BE COMPLETED. Failure to answer any question on this form may result in a late penalty, involuntary dissolution or revocation. 7. Address, including street and number, of Corporation's Principal Office: Number and Street City Is this corporation a Homeowner's Association that administers a common-interest community as defined in subsection (c) of Section 9-102 of the Code of Civil Procedure? (check one) I Yes I No Is this corporation a Cooperative Housing Corporation defined in Section 216 of the Internal Revenue Code of 1954? (check one) I Yes I No Under penalties of perjury and as an authorized officer, I declare that this Annual Report, pursuant to the provisions of the General Not for Profit Corporation Act, has been examined by me and is to the best of my knowledge and belief, true, correct and complete. ________________________________________________________________________________________________ State ZIP Code ITEM 8 MUST BE SIGNED. 8. BY: _________________________________________________________________________________________ Authorized Officer's Signature Title Date Printed by authority of the State of Illinois. December 2014 -- 1 -- C 54.26 American LegalNet, Inc. www.FormsWorkFlow.com Under the General Not For Profit Corporation Act, this Annual Report must be properly executed and filed in the Office of the Secretary of State prior to the first day of the corporation's anniversary month each year. If filed on time, a $10 filing fee only is required by statute. If filed later, a statutory $3 penalty fee must be added. This Annual Report must be properly completed and submitted to the Office of the Secretary of State. Item 1: In the event of a change of corporate name, the Articles of Amendment (Form NFP 110.30) must be filed. NOTICE Item 2: A registered agent and/or registered office may not be changed on an Annual Report. To change the registered agent and/or registered office, Form NFP 105.10/105.20 must be filed with the Secretary of State. This form may be downloaded at www.cyberdriveillinois.com (click Departments, Business Services, Publications and Forms). · The information requested must be given as the date of the execution of this report. · This report must be signed by an authorized officer of the corporation. DEFINITIONS · If this report is not filed, the corporation, if domestic, is subject to dissolution, or if foreign, is subject to having the authority revoked. · "Anniversary" means the day each year exactly one year or more years after: (1) the date on the Articles of Incorporation issued under Section 102.15 of this Act, if a domestic corporation. (2) the date on the Application for Authority issued under Section 113.20 of the Act, if a foreign corporation. · "Anniversary month" means the month in which the anniversary of the corporation occurs. American LegalNet, Inc. www.FormsWorkFlow.com