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Petition for Refund or Review (Illinois)

This form is to petition for refund or review of fees submitted to Illinois. The form provided here is simply a sample of what the actual Form BCA-1.17 looks like.

Form BCA-1.17

Jesse White
Secretary of State
Department of Business Services
Springfield, IL 62756
Telephone (217) 785-2237
(217) 785-6033

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


File # ________________________________


This space for use by Secretary of State

Date ________________________________

Filing Fee $ 5.00

Approved: ________________________________



1. CORPORATE NAME: ________________________________


3. Nature of claim: (Mark an "X" in one box only)

____ Refund

____ Adjustment or assessment

4. Amount of Claim $________________________________

No refund shall be made from an overpayment of less than $200.
Any amount to be refunded shall be reduced by $200.
The $200 restrictions DO NOT apply to adjustments of assessments.

5. Reason for claim and facts relied upon:
(If there is not sufficient space to cover this point, use reverse side or add one or more sheets of this size.)



6. 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)

by ________________________________ (Signature of President or Vice President)

________________________________ (Type or Print Name and Title)

________________________________ (Type or Print Name and Title)

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