State of Illinois
Art Auction House
Annual Registration Statement and Declaration
Secretary of State Index Department
111 E. Monroe
Springfield, IL 62756
217-782-7017
www.cyberdriveillinois.com
Registrations expire one year from the date of filing.
Return completed form to: Secretary of State, Index Department, 111 E. Monroe, Springfield, IL 62756 • 217-782-7017
A file stamped copy will be returned as your receipt. It is the responsibility of the
Art Auction House to annually file this statement with the Secretary of State.
To the Secretary of State:
In compliance with the requirements of 225 ILCS 405/1-405/4, “An Act concerning art auction houses,” the art auction house named
below has established and maintains a separate account for sellers for whom the art auction house has acted as agent.
1. Name, Address and Telephone Number of Art Auction House:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
2. Owner’s Name and Address:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
3. Name and Address of Bank or Savings and Loan Association in which a Separate Account for Customer Funds is Maintained:
___________________________________________________________________________________________________________
_______________________________________________________
4. Account Number: ___________________________________________________________________________________________
I declare that the foregoing statements are true and correct.
____________________________________________________
____________________________________________________
Subscribed to before me this ____________ day of __________________, 20_____.
____________________________________________________
Printed by authority of the State of Illinois. December 2009 — 50 — I 216
Signature
Notary Public
Official Capacity
Name Address
Telephone Number
City, State, ZIP Code
Name Address
If Corporation, State of Incorporation and Name of Registered Agent
City, State, ZIP Code
Name Address
City, State, ZIP Code
