FORM BCA 14.05 (rev. Oct. 2014) FOREIGN 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 Print Reset Save 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: Payment must be made by check or money order payable to Secretary of State. 3a. 3b. 4. 2. State or Country of Incorporation:__________________________________ Names and Addresses of Officers and Directors: NAME Month Day Principal Address of Corporation: ____________________________________________________________________________ Street City State ZIP Code Year County: Date Qualified to do Business in Illinois:__________________________________ NOTE: The names and addresses of ALL officers and directors must be entered in this item or on an additional sheet. Secretary Director Director Director President OFFICE NUMBER& STREET CITY STATE ZIP Treasurer 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 ________________________): SERIES PAR VALUE NUMBER AUTHORIZED n Female Owned CLASS 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.) Item 8 Must Be Signed. 8. 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. By: ___________________________________________________________________________________________________ Any Authorized Officer's Signature Printed by authority of the State of Illinois. January 2015 -- 1 -- C 288.7 Please Complete Reverse Side of This Report Title Date 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 ________________________________________ , ________________. Value of property (gross assets): Day Month Year Gross amount of business transacted by the corporation: (b) of the corporation located within the State of Illinois:.................................................. (b) (a) owned by the corporation, wherever located: ............................................................. (a) $ ______________________ $ ______________________ $ ______________________ $ ______________________ (d) at or from places of business in Illinois for the above period: ..................................... (d) ALLOCATION FACTOR = b+d a+c = = (c) everywhere for the above period: ............................................................................... (c) 10a. n 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. n 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.) ____________________ Enter this figure on line 11b below. 6 decimal places . STOP: Item 9 or 10 must be completed before continuing to Item 11. 11. 11a. 11b. 11c. 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.).................................................________________________ ANNUAL FRANCHISE TAX AND FEES 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 late or part thereof (minimum $1)...........................................................................________________________ e2. 11e3. INTEREST & PENALTIES (Add lines e1 and e2.) ................................................................................................. e3. 11g. 11f. ANNUAL REPORT FILING FEE ($75) .................................................................................................................. 11f. TOTAL ANNUAL FRANCHISE TAX, FEES, INTEREST, PENALTIES DUE (Add line d2 + line e3 + line f.) ...............................................................................................................................11g. + 75.00 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. MAKE CHECKS PAYABLE TO ILLINOIS SECRETARY OF STATE. (Place corporate file number on check.) American LegalNet, Inc. www.FormsWorkFlow.com