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Form NFP 104.15/20              (Rev. Aug. 2014)
APPLICATION TO ADOPT, CHANGE OR
CANCEL an ASSUMED               CORPORATE NAME
General Not For Profit Corporation Act
Secretary of State 
Department of Business Services
501 S. Second St., Rm. 350
Springfield, IL 62756
217-782-9520
217-782-6961
www.ilsos.gov
Payment must be made by check or money order
payable to Secretary of State.
         Filing fee $ _________________________  File #  ___________________________ Approved: _________________
———— Submit in duplicate ———— Type or Print clearly in black ink ———— Do not write above this line ———— 

1. Corporate Name: ________________________________________________________________________________
2. State or Country of Incorporation: ___________________________________________________________________
3. Date Incorporated (if an Illinois corporation) or Date Authorized to Transact Business in Illinois (if a foreign corporation):
_________________________________________________.
                              Month & Day                    Year

                   Complete No. 4 and No. 5 if adopting or changing an assumed corporate name.

4. Corporation intends to adopt and to transact business under the assumed corporate name of:
______________________________________________________________________________________________

5. The right to use the assumed corporate name shall be effective from the date this application is filed by the Secretary

of State until _______________________________________________, the first day of the corporation’s anniversary
                                      Month & Day                Year
month in the next year evenly divisible by five.

                              Complete No. 6 if changing or cancelling an assumed corporate name.

6. Corporation intends to cease transacting business under the assumed corporate name of:
______________________________________________________________________________________________

7. 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

          ______________________________________
                           Any Authorized Officer’s Signature

          ______________________________________
                              Name and Title (type or print)

NOTE:    The filing fee to adopt an assumed corporate name is $150 if the current year ends with a 0 or 5; $120 if the current
         year ends with a 1 or 6; $90 if the current year ends with a 2 or 7; $60 if the current year ends with a 3 or 8; or $30
         if the current year ends with a 4 or 9.
         The fee for cancelling an assumed corporate name is $5.
         The fee to change an assumed name is $5.

                                      Printed by authority of the State of Illinois. January 2015 — 1 — C 211.9