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FORM BCA 14.05 
DOMESTIC CORPORATION 
ANNUAL REPORT 
Business Corporation Act 
 
Secretary of State 
Department of Business Services 
501 S. Second St., Rm. 350 
Springfield, IL 62756 
217-782-7808 
ilsos.gov 
 
Payment must be made by check or money 
order payable to Secretary of State.
File Prior To: _________________________  Year: _________________ File #: _______________________ Approved: ___________ 
 
Note: A change in the Registered Agent and/or Registered Office may only be affected by filing form BCA-5.10/5.20.  
 
1.       Corporate Name: 
      Registered Agent: 
      Registered Office: 
      City, IL, ZIP Code:                                                    County: 
  
1a.   Is this corporation a publicly held corporation with outstanding shares listed on a major U.S. stock exchange and has its principal 
      executive office located in Illinois, as defined by Section 8.12?   n YES   n NO    If yes, form BCA 8.12 must be completed. 
 
1b.   Is this corporation required to file form EEO-1?   n YES   n NO    If yes, Section D of the EEO-1 form must be attached. 
                      FAILURE TO COMPLETE 1a and 1b WILL CAUSE THE REPORT TO BE RETURNED. 
                                                                           
2.    Principal Address of Corporation:                                                                                                                                                     
                                                           Street                               City                   State                                                      ZIP Code 
3.    Date Incorporated:__________________________________ 
                              Month            Day         Year 
4.    Names and addresses of officers and directors: 
NOTE: The names and addresses of ALL officers and directors must be entered in this item or on an additional sheet. 
   OFFICE                     NAME                       NUMBER & STREET                        CITY        STATE                                                                 ZIP 
  President 
  Secretary 
  Treasurer 
   Director 
   Director 
   Director 
5.    If 51% or more of stock is owned by a minority or female, please check appropriate box:  n Minority Owned     n  Female Owned 
6.    Number of shares authorized and issued (as of ________________________): 
       
   CLASS                   SERIES                    PAR VALUE                    NUMBER AUTHORIZED                    NUMBER ISSUED 
 
IMPORTANT:    If the amount in item 6 or 7a differs from the Secretary of State’s records, form BCA 14.30 must be completed. 
7a.   Amount of Paid-in Capital (as of ________________________________ ):  $ ________________________________________ 
7b.   Paid-in Capital on record with Secretary of State: $ _____________________________________________________________ 
                                 (Paid-in Capital reflects the sum of the Stated Capital and Paid-in surplus accounts.)
      Under the penalty of perjury and as an authorized officer, I declare that this annual report, pursuant to provisions of the Business 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:  ___________________________________________________________________________________________________ 
            Any authorized officer’s signature                  Title                                                                                                        Date 

                                    Please complete reverse side of this report.
                                 Printed by authority of the State of Illinois. December 2022 — 1 — C 289.18

ItemOR9  10a  OR10b, whichever is applicable,                 MUST be completed. 
 
9.    Amounts stated in parts (a) through (d) below are given for the 12-month period 
      ending ________________________________________ , ________________. 
                       Day                        Month           Year 
 
      Value of property (gross assets): 
           (a) owned by the corporation, wherever located:............................................................. (a)         $ ______________________ 
           (b) of the corporation located within the State of Illinois:.................................................. (b)       $ ______________________ 
      Gross amount of business transacted by the corporation: 
           (c) everywhere for the above period: ............................................................................... (c) $ ______________________ 
           (d) at or from places of business in Illinois for the above period:..................................... (d)             $ ______________________ 
       
      ALLOCATION FACTOR  =              b + d     =     ____________________ .Enter this figure on line 11b below. 
                                        a + c       =   6 decimal places 

10a.  n  ALL property of the Corporation is located in Illinois and ALL business of the Corporation is transacted at or from places of busi-
         ness in Illinois. 

10b.  n  The Corporation elects to pay franchise tax on the basis of 100% of its total Paid-in Capital. 

      IF SELECTING 10a or 10b, PLACE THE ALLOCATION FACTOR 1.000000 ON LINE 11b BELOW. 
 
STOP: Item 9 or 10 must be completed before continuing to Item 11. 

11.   ANNUAL FRANCHISE TAX AND FEES 

11a.  TOTAL PAID-IN CAPITAL (Enter amount from Item 7a;                                                             a. 
      if late, enter the greater of 7a or 7b.) ....................................................................._________________________ 
                                                                                                                    b. 
11b.  ALLOCATION FACTOR (Enter from Item 9 or Item 10.)........................................                     _________________________ 
                                                                                                                    c. 
11c.  ILLINOIS CAPITAL (Multiply line 11a by line 11b.).................................................________________________ 
                                                                                                                    d1 
11d1. Multiply line 11c by .001 (Round to nearest cent. Minimum amount $25)..............                            
11d2. ANNUAL FRANCHISE TAX (Enter amount from line d1, *SEE NOTE BELOW.) ................................................. d2. 

11e1. If Annual Report is late, multiply line d2 by .10 ......................................................________________________e1. 
11e2. If Annual Franchise Tax is late, multiply line d2 by .02 for each month 
      late or part thereof (minimum $1)...........................................................................________________________e2. 
11e3. INTEREST & PENALTIES (Add lines e1 and e2.)................................................................................................. e3.  

11f.  ANNUAL REPORT FILING FEE ($75) .................................................................................................................. 11f. + 75.00 

11g.  TOTAL ANNUAL FRANCHISE TAX, FEES, INTEREST, PENALTIES DUE 
      (Add line d2 + line e3 + line f.) MINIMUM TOTAL DUE IS $75 .............................................................................11g. 
*Note regarding annual franchise tax: Please see filing periods set forth below regarding the exemption amount for each year. 
 
                                          Franchise Tax Liability Exemption Amounts 
FILING PERIOD            EXEMPTION AMOUNT           TAX AMOUNT TO BE PLACED IN LINE D2 ABOVE 
1/1/20 - 12/31/20               Exemption $30                            (Tax amount in d1-$30=d2. If negative number, please place 0 in d2.)                         
1/1/21 and after                Exemption $1,000                       (Tax amount in d1-$1,000=d2. If negative number, please place 0 in d2.) 
 
                           MAKE CHECKS PAYABLE TO ILLINOIS SECRETARY OF STATE. 
                                              (Place corporate file number on check.) 

                                                        IMPORTANT: 
           If there have been changes in items 6 or 7, form BCA 14.30 must be executed 
                       and submitted with this Annual Report in the same envelope.