Fillable FORM NFP 104.10 (rev. Aug. 2014): PPLICATION FOR (Illinois Secretary of State)

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FORM NFP 104.10 (rev. Aug. 2014): PPLICATION FOR (Illinois Secretary of State)

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FORM NFP 104.10 (rev. Aug. 2014)
A
PPLICATION FOR RESERVATION OF NAME
Under the General Not For Profit Corporation Act
Secretary of State
Department of Business Services
501 S. Second St., Rm. 350
Springfield, IL 62756
217-782-9520
217-782-6961
w
ww.cyberdriveillinois.com
Payment must be made by check or money
order payable to Secretary of State.
($25 fee to each name reserved.)
Pursuant to the provisions of "The General Not For Profit Corporation Act of 1986," the undersigned hereby
submits the following Application for Reservation of Name.
1. The following name or names shall be reserved for a period of 90 days each:
________________________________________________________________________________
________________________________________________________________________________
2. A brief summary of the purpose intended to be conducted by the corporation is:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
3. Name of applicant: __________________________________________________________________
4. Address of applicant: ________________________________________________________________
________________________________________________________________________________
Date: ________________________________
____________________________________ ______________________________________
____________________________________ ______________________________________
NOTE: If the applicant is an individual, it is to be signed by the applicant.
If the applicant is a corporation, it is to be signed by the corporation's president or vice-president
and verified by him/her and attested to by the secretary or an assistant secretary.
(M
o
n
th
D
a
y)
(Year)
(May contain the word "corporation", "incorporated", or "limited", or may contain an abbreviation of one such word)
Signature of Applicant
Printed by authority of the State of Illinois. January 2015– 1 – C 140.12
File #  ___________________________ Approved: _________________
———— Type or Print clearly in black ink ———— Do not write above this line ————
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NOTICE OF TRANSFER
OF
R
ESERVED NAME
The undersigned _______________________________________________________hereby transfers
to _______________________________________________________________________the right to use the
name _________________________________________________________________for corporate purposes
in Illinois. This name was reserved on _________________________________________________________
The undersigned affirms, under penalties of perjury, that the facts stated herein are true.
Dated__________________________________ By: ____________________________________________
Attested by: _____________________________ ____________________________________________
* As the original applicant, I declare that this document has been examined by me and is to the best of
my knowledge and belief, true, correct and complete.
Date
Filing Fee$25
Approved
(Type or Print Name)
If a corporation, by its president or vice president
(Name of Original Applicant)
(Signature of Original Applicant)
(
Month Day)
(
Y
ear
)
C-140.10
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FORM NFP 104.10 (rev. Aug. 2014): PPLICATION FOR (Illinois Secretary of State)

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Completed 9 August 2021

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