FORM BCA-14.35 (rev. Dec. 2014) Report Following Merger or Consolidation 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. 1. Corporate Name: ________________________________________________________________________________ 3. Issued shares of each corporation party to the merger prior to the merger: Corporation Class Series Franchise Tax: $_________ Filing Fee: $5 Penalty: $_________ Interest: $_________ Total: $_________ ________ Type or Print clearly in black ink ________ Do not write above this line ________ File #: ___________________________ Approved: ______________________ 2. State or Country of Incorporation: ___________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ $ ________________________________________________________________________________________________ $ ________________________________________________________________________________________________ $ ________________________________________________________________________________________________ $ ________________________________________________________________________________________________ (Include effective date and brief explanation of the conversion as stated in the plan of merger.) Corporation Paid-in Capital Par Value Number of Shares 4. Paid-in Capital of each corporation party to the merger prior to the merger: 5. Description of merger: 6. Issued shares after merger: Class 7. Paid-in Capital of the surviving or new corporation: $ ________________ ITEM 8 MUST BE SIGNED ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ("Paid-in Capital" replaces the terms Stated Capital and Paid-in Surplus and is equal to the total of these accounts.) Series Par Value Number of Shares 8. 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 Printed by authority of the State of Illinois. October 2015-- 1 -- C 243.5 American LegalNet, Inc. www.FormsWorkFlow.com