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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
S pringfield, IL 62756
217-782-9520
217-782-6961
www.cyberdriveillinois.com
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