Fillable FORM BCA 14.05 (rev. Oct. 2019): DOMESTIC CORPORATION (Illinois Secretary of State)

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FORM BCA 14.05 (rev. Oct. 2019): DOMESTIC CORPORATION (Illinois Secretary of State)

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File Prior To: _________________________ Year: _________________ File #: _______________________ Approved: ___________
Note: A change in the Registered Agent and/or Registered Office may only be affected by filing form BCA-5.10/5.20.
1. Corporate Name:
Registered Agent:
Registered Office:
City, IL, ZIP: County:
1a. Is this corporation a publicly held corporation with outstanding shares listed on a major U.S. stock exchange and has its principal
executive office located in Illinois, as defined by Section 8.12? YES NO If yes, complete form BCA 8.12.
2. Principal address of corporation:
Street City State ZIP
3. Date incorporated:__________________________________
Month Day Year
4. Names and addresses of officers and directors:
NOTE: The names and addresses of ALL officers and directors must be entered in this item or on an additional sheet.
OFFICE NAME NUMBER & STREET CITY STATE ZIP
President
Secretary
Treasurer
Director
Director
Director
5. If 51 percent or more of stock is owned by a minority or female, please check the appropriate box: Minority Owned Female Owned
6. Number of shares authorized and issued (as of ________________________):
CLASS SERIES PAR VALUE NUMBER AUTHORIZED NUMBER ISSUED
IMPORTANT: If the amount in item 6 or 7a differs from the Secretary of State’s records, form BCA 14.30 must be completed.
7a. Amount of Paid-in Capital (as of ________________________________ ): $ ________________________________________
7b. Paid-in Capital on record with Secretary of State: $ _____________________________________________________________
Item 8 Must Be Signed.
8. By: ___________________________________________________________________________________________________
Any authorized officer’s signature Title Date
Please complete reverse side of this report.
(Paid-in Capital reflects the sum of the Stated Capital and Paid-in surplus accounts.)
Printed by authority of the State of Illinois. February 2021 — 1 — C 289.16
FORM BCA 14.05 (rev. Oct. 2019)
DOMESTIC CORPORATION
ANNUAL REPORT
Business Corporation Act
Secretary of State
Department of Business Services
501 S. Second St., Rm. 350
Springfield, IL 62756
217-782-7808
www.cyberdriveillinois.com
Payment must be made by check or money
order payable to Secretary of State.
Under the penalty of perjury and as an authorized officer, I declare that this annual report, pursuant to provisions of the Business Corporation Act, has been
examined by me and is, to the best of my knowledge and belief, true, correct and complete.
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a.
b.
c.
d1
e1.
e2.
.
+ 75.00
Item 9 OR 10a OR 10b, whichever is applicable, MUST be completed.
9. Amounts stated in parts (a) through (d) below are given for the 12-month period
ending ________________________________________ , ________________.
Day Month Year
Value of property (gross assets):
(a) owned by the corporation, wherever located: ............................................................. (a) $ ______________________
(b) of the corporation located within the State of Illinois:.................................................. (b) $ ______________________
Gross amount of business transacted by the corporation:
(c) everywhere for the above period: ............................................................................... (c) $ ______________________
(d) at or from places of business in Illinois for the above period: ..................................... (d) $ ______________________
ALLOCATION FACTOR = b + d = ____________________ Enter this figure on line 11b below.
a + c = 6 decimal places
10a. ALL property of the Corporation is located in Illinois and ALL business of the Corporation is transacted at or from places of busi-
ness in Illinois.
10b. The Corporation elects to pay franchise tax on the basis of 100 percent of its total Paid-in Capital.
IF SELECTING 10a or 10b, PLACE THE ALLOCATION FACTOR 1.000000 ON LINE 11b BELOW.
STOP: Item 9 or 10 must be completed before continuing to Item 11.
11. ANNUAL FRANCHISE TAX AND FEES
11a. TOTAL PAID-IN CAPITAL (Enter amount from Item 7a;
if late, enter the greater of 7a or 7b.) .....................................................................
_________________________
11b. ALLOCATION FACTOR (Enter from Item 9 or Item 10.)........................................
_________________________
11c. ILLINOIS CAPITAL (Multiply line 11a by line 11b.).................................................________________________
11d1. Multiply line 11c by .001 (Round to nearest cent. Not less than $25.00) ...............
11d2. ANNUAL FRANCHISE TAX (Enter amount from line d1, *SEE NOTE BELOW.)..................................................
d2.
11e1. If Annual Report is late, multiply line d2 by .10 ......................................................________________________
11e2. If Annual Franchise Tax is late, multiply line d2 by .02 for each month
late or part thereof (minimum $1)...........................................................................________________________
11e3. INTEREST & PENALTIES (Add lines e1 and e2.).................................................................................................
e3
.
11f. ANNUAL REPORT FILING FEE ($75) ..................................................................................................................
11f.
11g.
TOTAL ANNUAL FRANCHISE TAX, FEES, INTEREST, PENALTIES DUE
(Add line d2 + line e3 + line f.) TOTAL MINIMUM DUE IS $75..............................................................................
11g.
*Note regarding annual franchise tax: Please see filing periods set forth below regarding the exemption amount of each year.
Franchise Tax Liability Exemption Amounts
FILING PERIOD EXEMPTION AMOUNT TAX AMOUNT TO BE PLACED IN LINE D2 ABOVE
1/1/20-12/31/20 Exemption $30.00 (Tax amount in d1-$30=d2. If negative number, please place 0 in d2.)
1/1/21-12/31/21 Exemption $1,000.00 (Tax amount in d1-$1,000=d2. If negative number, please place 0 in d2.)
1/1/22-12/31/22 Exemption $10,000.00 (Tax amount in d1-$10,000=d2. If negative number, please place 0 in d2.)
1/1/23-12/31/23 Exemption $100,000.00 (Tax amount in d1-$100,000=d2. If negative number, please place 0 in d2.)
1/1/24 and after No Franchise Tax Due
MAKE CHECKS PAYABLE TO ILLINOIS SECRETARY OF STATE.
(Place corporate file number on check.)
IMPORTANT:
If there have been changes in items 6 or 7, form BCA 14.30 must be executed
and submitted with this Annual Report in the same envelope.
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FORM BCA 14.05 (rev. Oct. 2019): DOMESTIC CORPORATION (Illinois Secretary of State)

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Completed 12 March 2021

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