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Application For Certificate Of Withdrawal And Final Report (Illinois)

This form is to withdraw and submit a final report in Illinois. The form provided here is simply a sample of what the actual Form BCA-13.45 looks like.

Form BCA-13.45

Jesse White
Secretary of State
Department of Business Services
Springfield, IL 62756
Telephone (217) 785-2237
https://www.sos.state.il.us

Remit payment in check or money order, payable to "Secretary of State."

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File # ________________________________

SUBMIT IN DUPLICATE

This space for use by Secretary of State

Date ________________________________

License Fee $________________________________

Franchise Tax $________________________________

Filing Fee $25.00

Penalty $________________________________

Interest $________________________________

Approved: ________________________________


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APPLICATION FOR CERTIFICATE OF WITHDRAWAL AND FINAL REPORT

1. CORPORATE NAME: _________________________________


2. STATE OR COUNTRY OF INCORPORATION: _________________________________

3. Post office address to which may be mailed a copy of any process against the corporation that may be served on the Secretary of State:

_________________________________

_________________________________

4. No portion of its issued shares at this time is represented by business transacted or property located in this State.

5. It surrenders its authority to transact business in Illinois.

6. It revokes the authority of its registered agent in Illinois to accept service of process, and hereby consents that service of process in any suit, action or proceeding based upon any cause of action arising in this State during the time this corporation was licensed to transact business in this State may hereafter be made on such corporation by service thereof upon the Secretary of State.

7. (a) List all issuances of shares not previously reported to the Secretary of State (including shares issued for cash or other property, share dividends, share splits, share exchanges pursuant to Section 11.10, and shares to effect an exchange or reclassification of issued shares) and give the value of the entire consideration received therefor, less expenses; list any amounts added or transferred to paid-in capital, without the issuance of shares.

Date of Issuance or Contribution _________________________________

Class _________________________________

Par Value _________________________________

Number of Shares Issued _________________________________

Entire Consideration Received $_________________________________


Date of Issuance or Contribution _________________________________

Class _________________________________

Par Value _________________________________

Number of Shares Issued _________________________________

Entire Consideration Received $_________________________________

TOTAL Consideration Received $ _________________________________

(b) List all cancellations of shares not previously reported to the Secretary of State, and give the cost.

Date of Cancellation _________________________________

Class _________________________________

Number of Shares Cancelled _________________________________

Cost $_________________________________


Date of Cancellation _________________________________

Class _________________________________

Number of Shares Cancelled _________________________________

Cost $_________________________________

TOTAL Cost $_________________________________

8. Issued shares at date of execution:

Class _________________________________

Series _________________________________

Par Value _________________________________

Number of Shares _________________________________

9. Paid-in capital at date of execution:

Paid-in Capital: $_________________________________

("Paid-in Capital" replaces the terms Stated Capital & Paid-in Surplus and is equal to the total of these accounts.)

10. The undersigned corporation has caused this statement to be signed by its duly authorized officers, each of whom affirms, under penalties of perjury, that the facts stated herein are true. (All signatures must be in BLACK INK.)

Dated __________________________ (Month & Day), _________ (Year)

_________________________________ (Exact Name of Corporation)

attested by _________________________________ (Signature of Secretary or Assistant Secretary)

_________________________________ (Type or Print Name and Title)

by _________________________________ (Signature of President or Vice President)

_________________________________ (Type or Print Name and Title)

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