1.Limited Liability Company name: 2.State or country of organization:3.Amount of claim:No refund shall be made for an overpayment of less than $200.Any amount to be refunded shall be reduced by $200.4.Details of transaction and all facts upon which the petitioner relies: (If there is not sufficient space to cover this point, attach additional sheets of this size.)5. I affirm, under the penalties of perjury, having the authority to sign hereto, that this Petition for Refund is to the best ofmy knowledge and belief, true, correct and complete.Date:, FormLLC-5.48July 2017Illinois Limited Liability Company ActPetition for RefundIf applicant is signing for a company or other entity, state name of company. Name and Title (type or print)Month/DayYearPrinted by authority of the State of Illinois. December 2017 321 1 321 LLC 35.6 Filing Fee: $5Approved: SUBMIT!IN!DUPLICATEType or print clearly.SignatureSecretary of State Department of Business ServicesLimited Liability Division501 S. Second St., Rm. 351Springfield, IL 62756217-524-8008www.cyberdriveillinois.com Payment may be made by checkpayable to Secretary of State. Ifcheck is returned for any reasonthis filing will be void. This space for use by Secretary of State.FILE # American LegalNet, Inc. www.FormsWorkFlow.com