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Cumulative Report Of Changes In Issued Shares And In Paid-In Capital (Illinois)

This form the cumulative report of issued shares in Illinois. The form provided here is simply a sample of what the actual Form BCA-14.30 looks like.

Form BCA-14.30

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

-------------------------------

File # ________________________________

Date ________________________________

License Fee $________________________________

Franchise Tax $________________________________

Filing Fee $________________________________

Penalty $________________________________

Interest $________________________________

Approved: ________________________________


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CUMULATIVE REPORT OF CHANGES IN ISSUED SHARES AND IN PAID-IN CAPITAL

1. CORPORATE NAME: _________________________________

2. STATE OR COUNTRY OF INCORPORATION: ________________________

3. Authorized and issued shares as last reported.*

Class _________________________________

Series _________________________________

Par Value _________________________________

Number Authorized _________________________________

Number Issued _________________________________

Class _________________________________

Series _________________________________

Par Value _________________________________

Number Authorized _________________________________

Number Issued _________________________________

Class _________________________________

Series _________________________________

Par Value _________________________________

Number Authorized _________________________________

Number Issued _________________________________

4. Paid-in Capital as last reported:* $__________________________
*In any document other than an annual report

5. CURRENT REPORTING PERIOD TRANSACTIONS: (NOTE 1)

* List the total issuances and exchanges of shares by class not previously reported to the Secretary of State and give the value of the entire consideration received (less expenses paid or incurred in connection with such issuances) and added or transferred to paid-in capital for or on account of such shares.

* List the total amount added or transferred to paid-in capital without the issuance of shares. (Contributions)

* List the total of all cancellations of shares by class not previously reported to the Secretary of State and the cost to paid-in capital for acquiring such shares.

* List the total amount subtracted from paid-in capital without a cancellation of shares, but as permitted by Section 9.20 of the Illinois Business Corporation Act. (Reductions) Issuance or Contributions

Class of Shares _________________________________

Series _________________________________

Par Value _________________________________

Number of Shares _________________________________

Consideration Received/Cost $______________________________

Class of Shares _________________________________

Series _________________________________

Par Value _________________________________

Number of Shares _________________________________

Consideration Received/Cost $______________________________


Cancellations or Reductions (State reason for reduction if no shares were cancelled, see Note 6.)

Class of Shares _________________________________

Series _________________________________

Par Value _________________________________

Number of Shares _________________________________

Consideration Received/Cost $(______________________________)


Class of Shares _________________________________

Series _________________________________

Par Value _________________________________

Number of Shares _________________________________

Consideration Received/Cost $(______________________________)


Cumulative Change (enter on line (6a) below) (NOTE 2) $ _________________________________


6. FRANCHISE TAX AND FEES:
(No additional franchise tax is due when cumulative change is negative amount.)

(a.) CUMULATIVE CHANGE ........................ a. ____________________

(b.) APPLICABLE ALLOCATION FACTOR (NOTE 3) ........................... b. ___________________________

(c.) TAXABLE ILLINOIS CAPITAL (Multiply line (a) by line (b)....... c ___________________________

(d.) Multiply line (c) by .0015 (Round to nearest cent) .................... d ___________________________

(e.) ADDITIONAL FRANCHISE TAX (Enter amount from line (d).. e ___________________________

(f.) If Cumulative Report is late, multiply line (e) by .10 (Penalty).. f ___________________________

(g.) If Additional Franchise Tax is late, multiply line (e) by .01 for each month late or part thereof (Interest) .................. g __________________

(h.) FILING FEE ($5) .................................................. h $5.00

(i.) TOTAL AMOUNT DUE (Add line (e) + line (f) + line (g) + line (h)) . I ________________________

8 & 9 MUST BE COMPLETED

7. TRANSACTIONS OCCURRING DURING PREVIOUS REPORTING PERIOD(S) AND NOT REPORTED TO THE SECRETARY OF STATE; (note 4)

(The Secretary of State will compute fees, taxes, and penalties resulting from the following transactions.)

Issuance or Contributions

Date _________________________________

Class of Shares _________________________________

Series _________________________________

Par Value _________________________________

Number of Shares _________________________________

Consideration Received/Cost $_________________________________

Date _________________________________

Class of Shares _________________________________

Series _________________________________

Par Value _________________________________

Number of Shares _________________________________

Consideration Received/Cost $_________________________________

Cancellations or Reductions (State reason for reduction if no shares were canceled, see Note 6.)

Date _________________________________

Class of Shares _________________________________

Series _________________________________

Par Value _________________________________

Number of Shares _________________________________

Consideration Received/Cost $(______________________________)


Date _________________________________

Class of Shares _________________________________

Series _________________________________

Par Value _________________________________

Number of Shares _________________________________

Consideration Received/Cost $(______________________________)

8. Authorized and issued shares after changes:

Class _________________________________

Series _________________________________

Par Value _________________________________

Number Authorized _________________________________

Number Issued _________________________________


Class _________________________________

Series _________________________________

Par Value _________________________________

Number Authorized _________________________________

Number Issued _________________________________


Class _________________________________

Series _________________________________

Par Value _________________________________

Number Authorized _________________________________

Number Issued _________________________________


9. Paid-in Capital after changes: $______________________________

("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.

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)


NOTES

Note 1. "Current reporting period" for a corporation which has not established an extended filing month means the 12 month period ending with the last day of the third month prior to its anniversary month in the current year. In the case of a corporation which has established an extended filing month, the "current reporting period" refers to the 12 month period ending with the corporation's most recent fiscal year end.

Note 2. "Cumulative change" means the difference arrived at by subtracting all reductions, as permitted by Section 9.20 of the Illinois Business Corporation Act, in paid-in capital (if any) from all increases in paid-in capital (if any). However, reductions reported on a document filed after the statutory due date cannot be netted against increases and do not reduce the basis for the annual franchise tax until the subsequent year.

Note 3. "Applicable allocation factor" means the allocation factor established at the time of filing the annual report for the previous year. However, if no annual report was filed for the previous year, the applicable allocation factor will be that factor established on the articles of incorporation for a domestic corporation or on the application for original certificate of authority for a foreign corporation.

Note 4. "Previous reporting period" means any time period occurring prior to the current reporting period.

Note 5. If there have been changes reported in item 5 or 7 of the 14.30, Form 14.30 must be submitted with the enclosed Annual Report, in the same envelope.

Note 6. Pursuant to Section 9.20 of the Illinois Business Corporation Act, paid-in capital may be reduced without cancellation of shares only through dividends paid on preferred shares, distributions as liquidating dividends or pursuant to an approved reorganization in bankruptcy that specifically directs the reduction to be effected.

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