FORM BCA-1.17 (rev. Dec. 2014) Petition for Refund or Review Business Corporation Act Department of Business Services 501 S. Second St., Rm. 350 Springfield, IL 62756 217-782-6961 www.cyberdriveillinois.com Payment must be made by check or money order payable to Secretary of State. Filing Fee: $5 11. Corporate Name: _______________________________________________________________________________ 13. Nature of Claim: (Mark an "X" in one box only.) ________ Submit in duplicate ________ Type or Print clearly in black ink ________ Do not write above this line ________ File #: ___________________________ Approved: ______________________ 12. State or Country of Incorporation: __________________________________________________________________ 14. Amount of Claim: $________________________________ o Refund o Adjustment of Assessment 15. Reason for Claim and Facts Relied Upon: (For more space, use reverse side or attach additional sheets of this size.) · No refund will be made from an overpayment of less than $200. · Any amount to be refunded will be reduced by $200. · The $200 restrictions DO NOT apply to adjustments of assessments. 16. 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 _______________________________ , _____ by ______________________________________ Any Authorized Officer's Signature Name and Title (type or print) Month Day Year ________________________________________________ Exact Name of Corporation ______________________________________ Printed by authority of the State of Illinois. January 2015 -- 1 -- C 198.9 American LegalNet, Inc. www.FormsWorkFlow.com