Reset
FORM BCA-1.17       (rev. Dec. 2014)
Petition for Refund or Review
Business Corporation Act
Department of Business Services
501 S. Second St., Rm. 350
Springfield, IL  62756
217-782-6961
www.ilsos.gov

Payment must be made by check or money 
order payable to Secretary of State. 

             Filing Fee: $5          File #: ___________________________     Approved: ______________________
 ________ Submit in duplicate ________ Type or Print clearly in black ink ________ Do not write above this line ________

11. Corporate Name: _______________________________________________________________________________

12. State or Country of Incorporation: ____ ______________________________________________________________

13. Nature of Claim:   (Mark an “X” in one box only.)   o Refund o Adjustment of Assessment

14. Amount of Claim: $________________________________
    • No refund will be made from an overpayment of less than $200.
    • Any amount to be refunded will be reduced by $200.
    • The $200 restrictions DO NOT apply to adjustments of assessments.

15. Reason for Claim and Facts Relied Upon:           (For more space, use reverse side or attach additional sheets of this size.)

16. The undersigned corporation has caused this statement to be signed by a duly authorized officer who affirms, under
    penalties of perjury, that the facts stated herein are true and correct.

    Dated _______________________________ ,  _____    ________________________________________________ 
                          Month   Day                     Year                Exact Name of Corporation

    by       ______________________________________
                      Any Authorized Officer’s Signature

             ______________________________________
                        Name and Title (type or print)
                               Printed by authority of the State of Illinois. January 2015 — 1 — C 198.9