1. Limited Liability Company name: ______________________________________________ _____________________
2. State or country of organization: ___________________________________________________________________
3. Amount of claim:________________________________________________________________________________
No refund shall be made for an overpayment of less than $200.
Any amount to be refunded shall be reduced by $200.
4. Details of transaction and all facts upon which the petitioner relies: ________________________________________
(If there is not sufficient space to cover this point, attach additional sheets of this size.)
5. I affirm, under the penalties of perjury, having the authority to sign hereto, that this Petition for Refund is to the best of
my knowledge and belief, true, correct and complete.
Date: _________________________, ___________
________________________________________
________________________________________
________________________________________
Form LLC-5.48
July 2017
Illinois
Limited Liability Company Act
Petition for Refund
If applicant is signing for a company or other entity,
state name of company.
Name and Title (type or print)
Month/Day
Year
Printed by authority of the State of Illinois. December 2017 — 1 — LLC 35.6
Filing Fee: $5
Approved:
SUBMIT IN DUPLICATE
Type or print clearly.
Signature
Secretary of State
Department of Business Services
Limited Liability Division
501 S. Second St., Rm. 351
Springfield, IL 62756
217-524-8008
www.cyberdriveillinois.com
Payment may be made by check
payable to Secretary of State. If
check is returned for any reason
this filing will be void.
This space for use by Secretary of State.
FILE #
