1. Limited Liability Company Name:____________________________________________________________________
Registered Agent:________________________________________________________________________________
Registered Office: _____________________________________________________________IL_________________
2. State or Country of Organization: ________________________ Date Organized in or Admitted to Illinois: _____________
3.
Address of Principal Place of Business: (P.O. Box alone is unacceptable.)
_______________________________________________________________________________________________
4. Names and Addresses of Managers or Members:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
5. Entity managers/members affirm their current existence.
6. Changes to the registered agent and/or registered office must be submitted on Form LLC-1.36/1.37.
7. I affirm, under penalties of perjury, having authority to sign thereto, that this Annual Report is to the best of my knowledge
and belief, true, correct and complete.
Dated: ___________________________, ______________
Month/Day Year
________________________________________________
Signature
________________________________________________
Name and Title (type or print)
________________________________________________
If applicant is a company or other entity, state Name of Company
and whether a member or manager of the LLC.
Form LLC-50.1
May 2012
Illinois
Limited Liability Company Act
Annual Report
Printed by authority of the State of Illinois. October 2014 — 1 — LLC 23.11
Type or Print Clearly.
This space for use by Secretary of State.
Filing Fee: $250
Series Fee, if required:
P
enalty:
Total:
Approved:
S
ecretary of State
Department of Business Services
Limited Liability Division
501 S. Second St., Rm. 351
Springfield, IL 62756
2
17-524-8008
www.cyberdriveillinois.com
Payment may be made by check
payable to Secretary of State. If
check is returned for any reason this
f
iling will be void.
T
his space for use by Secretary of State.
F
ILE #
D
ue prior to:
Number Street Suite City Zip
Number Street Suite City, State Zip
A late filing penalty of $300 will
apply if this report is not filed within
60 days after the due date.
Name Number & Street City, State Zip MGR/MBR
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