Form UPA-1004 October 2014 Secretary of State Department of Business Services Limited Liability Division 501 S. Second St., Rm. 357 Springfield, IL 62756 217-524-8008 www.cyberdriveillinois.com Application for Reinstatement Filing Fee: $200 Approved: SUBMITINDUPLICATE Type or Print Clearly. Illinois Uniform Partnership Act FILE # This space for use by Secretary of State. Total payment must be made by certified check, cashiers check, money order, IL attorney's check or IL C.P.A.'s check. If check is returned for any reason this filing will be void. 1. Partnership Name: ______________________________________________________________________ 2. Federal Employer Identification Number (F.E.I.N): ______________________________________________ 3. State of Jurisdiction: 5. Registered Agent: Registered Office: 4. Date of Expiration: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ IL Street Address City Zip ____________________________________________________________________ The undersigned declares, under penalties of perjury that the foregoing is true, correct and complete. This form must be signed by a partner. Month, Day Signature Dated:_________________________________20__________ ____________________________________ ____________________________________ ____________________________________ Partner Name if a Corporation or other Entity Name and Title (type or print) Year ________________________________________ ________________________________________ ________________________________________ State, Zip City, Town Street Address NOTE: Do Not make changes on this form. Use form UPA 1001(h)/1102(g) and submit with a $25 filing fee to report all changes. Printed by authority of the State of Illinois. November 2014 -- 1 -- UPA 17.1 American LegalNet, Inc. www.FormsWorkFlow.com