1. Corporation Name: _____________________________________________________________________________
2. Registered Agent: ______________________________________________________________________________
Registered Office: ______________________________________________________________________________
City, IL, ZIP, County: ____________________________________________________________________________
3a. Date of Incorporation/Qualification:___________________ 3b. State of Incorporation: ____________________
4. Names and Addresses of Corporation's Officers and Directors:
NAME OFFICE NUMBER & STREET CITY STATE ZIP
President
Secretary
Treasurer
Director
Director
Director
NOTE: List all officers and directors above or on an additional sheet. Illinois corporations must have three directors.
5. Brief statement of type of business the corporation is conducting:
6. Is this corporation a Condominium Association as established under the Condominium Property Act? (check one)
■
Yes
■
No
Is this corporation a Cooperative Housing Corporation defined in Section 216 of the Internal Revenue Code of 1954?
(check one)
■
Yes
■
No
Is this corporation a Homeowner's Association that administers a common-interest community as defined in sub-
section (c) of Section 9-102 of the Code of Civil Procedure? (check one)
■
Yes
■
No
ITEM 6 MUST BE COMPLETED. Failure to answer any question on this form may result in a late penalty, involuntary dis-
solution or revocation.
7. Address, including street and number, of Corporation's Principal Office:
________________________________________________________________________________________________
Number and Street City State ZIP Code
Under penalties of perjury and as an authorized officer, I declare that this Annual Report, pursuant to the provisions of the General
Not for Profit Corporation Act, has been examined by me and is to the best of my knowledge and belief, true, correct and complete.
ITEM 8 MUST BE SIGNED.
8. BY: _________________________________________________________________________________________
Authorized Officer’s Signature Title Date
Printed by authority of the State of Illinois. December 2014 — 1 — C 54.26
FORM NFP 114.05
(rev. Oct. 2014)
DOMESTIC/FOREIGN CORPORATION
ANNUAL REPORT
General Not for Profit Corporation Act
Secretary of State
Department of Business Services
501 S. Second St., Rm 350
Springfield, IL 62756
217-782-7808
www.ilsos.gov
Payment must be made by check or money
order payable to Secretary of State.
Filing Fee: $10 (if late, add $3 penalty fee.) Year: _________________ File #:_______________________ Approved: ___________
Note: A change in the Registered Agent and/or Registered Office may only be effected by filing Form NFP-105.10/105.20.
