FORM BCA-14.01 (rev. May 2015) STATEMENT OF ELECTION TO ESTABLISH AN EXTENDED FILING MONTH 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: $25 File #: ___________________________ Approved: ______________________ ________ Submit in duplicate ________ Type or Print clearly in black ink ________ Do not write above this line ________ 1. 2. 3. 4. 5. 6. CORPORATE NAME: ________________________________________________________________________ State or Country of Incorporation: ______________________________________________________________ Date Incorporated/Qualified: ___________________________________________________________________ Extended filing month (See Note 2.): ____________________________________________________________ Date of fiscal year end immediately preceding this election: __________________________________________ This Statement of Election is accompanied by an Interim Annual Report, which shall set forth, as of the date of filing of the statement, all of the information required pursuant to Section 14.05 of the Business Corporation Act to be included in the annual report, except that the information required by subparagraph (h) of Section 14.05 shall be the amounts represented in this state as disclosed by the preceding annual report, or, if no annual report is on file, from information contained in the articles of incorporation of a domestic corporation or the application for authority in the case of a foreign corporation. 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. _______________________________________ _______________________________________ (Type or Print Name and Title) (Any authorized Officer's signature) Month Day Year (Exact Name of Corporation) 7. Dated: _________________________ , ____________ by: ____________________________________________ FOR A CORPORATION SEEKING TO ESTABLISH AN EXTENDED FILING MONTH, SECTION 14.01 OF THE BUSINESS CORPORATION ACT REQUIRES THIS DOCUMENT BE FILED PRIOR TO THE FIRST DAY OF THE CORPORATION'S ANNIVERSARY MONTH. IMPORTANT! Printed by authority of the State of Illinois. May 2015 - 1 - C 242.8 American LegalNet, Inc. www.FormsWorkFlow.com Note 1: Each domestic corporation and each foreign corporation authorized to transact business in this state, having reported on its last annual report or if no annual report is on file, on the articles of incorporation of a domestic corporation or on the application for authority of a foreign corporation, an amount less than 100 percent of its paid-in capital represented in Illinois, may make an irrevocable, one time election to establish an extended filing month for the purpose of filing annual reports for all subsequent taxable years. Note 2: The extended filing month may be any month in that is one of the nine months consecutively following the end of the corporation's fiscal year, except that the extended filing month may not be one of the two months immediately preceding the corporation's anniversary month. Notwithstanding the foregoing, a corporation whose fiscal year ends within the two months immediately preceding its anniversary month may not elect an extended filing month. NOTES Note 3: When filing an Interim Annual Report DO NOT complete items 9 or 10. In calculating the interim annual franchise tax, the corporation must use the factor established from its last annual report or, if no annual report is on file, on the articles of incorporation of a domestic corporation or on the application for authority of a foreign corporation. This factor appears beneath the checklist on the preprinted annual report recently mailed to the corporation. American LegalNet, Inc. www.FormsWorkFlow.com Form BCA 14.05-I 1. 2. 3. CORPORATE NAME REGISTERED AGENT REGISTERED OFFICE CITY, IL, ZIP CODE Please Type or Print Clearly in Black Ink DOMESTIC/FOREIGN CORPORATION INTERIM ANNUAL REPORT STATE OF ILLINOIS YEAR OF _______ File # (b) State or Country of Incorporation: (a) Date of Incorporated/Qualified: ________________ (a) Give complete address of principal office, if other than above. ________________ 3. 4. 5. 6. Names and addresses of the officers and directors (If officers are directors, so state.): Name Number & Street City State President Secretary Treasurer Director Director Director Authorized and issued shares as of ____________________ : Class Series Par Value (Date) (b) FEIN No.: ____________________________________ _____________________________________________ _____________________________________________ ZIP Type of business actually conducted in Illinois: _______________________________________________ Number Authorized Number issued 7. (a) Paid-in capital as of ___________________ : (Date) (x) 8. PAID-IN CAPITAL $ __________________ ("Paid-in Capital" replaces the terms "Stated Capital" and "Paid-in Surplus." It does not include Retained Earnings.) (b) Paid-in Capital as of ________________________ , on record with the Secretary of State: TOTAL $ _____________________________ (Date) Previous Allocation Factor: ____________________ Under penalty of perjury and as an authorized officer, I declare that this annual report and, if applicable, the statement of change of registered agent and/or office, 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. American LegalNet, Inc. www.FormsWorkFlow.com By: ___________________________________________________________________________________ (Authorized Officers's Signature) (Title) (Date) ITEM 8 MUST BE SIGNED 9. 10. 11. Omitted INTERIM ANNUAL FRANCHISE TAX AND FEES (a.) Omitted (b.) (c.) Total Paid-in Capital (Enter the GREATER of item 7a or item 7b from other side of this annual report form) . . . . . . . . . . . . . . . . . . . . . . . . . a ALLOCATION FACTOR (Enter from item 7x from other side of this annual report) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b ILLINOIS CAPITAL (Multiply line (a) by line (b).) . . . . . . . . . . . . . . . . . . . . c (d1.) (d2.) (d3.) (e.) (f.) Illinois Capital (Enter from line (c).) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d1 ANNUAL FRAN