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7. Transactions occurring during previous reporting period(s) and not reported to the Secretary of State (See Note 4 below.):
The Secretary of State will compute fees, taxes and penalties resulting from the following transactions.)
Class of Number of Consideration
Date Shares Series Par Value Shares Received/Cost
________________________________________________________________________________________________
Issuance or $
Contributions: $
$
$
Cancellations $ ( )
or Reductions: $ ( )
(State reason for reduction if no shares were cancelled. See Note 6 below.) $ ( )
ITEMS 8 AND 9 MUST BE COMPLETED.
8. Authorized and Issued Shares after changes:
Class Series Par Value Number Authorized Number Issued
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
9. Paid-In Capital after changes: $ ______________________________
(“Paid-In Capital” replaces the terms Stated Capital and Paid-In Surplus and is equal to the total of these accounts.)
ITEM 10 MUST BE SIGNED.
10.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)
NOTES
1. “Current reporting period” for a corporation that has not established an extended filing month means the 12-month period ending with
the last day of the third month prior to its anniversary month in the current year. In the case of a cor poration that has established an
extended filing month, the “current reporting period” refers to the 12-month period ending with the corporation’s most recent fiscal
year end.
2. “Cumulative change” means the difference arrived at by subtracting all reductions as permitted by Section 9.20 of the Illinois
Business Corporation Act in paid-in capital (if any) from all increases in paid-in capital (if any). However, a net reduction in paid-in
capital reported on Form BCA 14.30 filed after the statutory due date does not reduce the basis for the annual franchise tax until the
subsequent year.
3. “Applicable allocation factor” means the allocation factor established at the time of filing the Annual Report for the previous year.
However, if no Annual Report was filed for the previous year, the applicable allocation factor will be that factor established on the
Articles of Incorporation for a domestic corporation or on the Application for Authority for a foreign corporation.
4. “Previous reporting period” means any time period occurring prior to the current reporting period.
5. If there have been changes reported in item(s) 5 or 7 on Form BCA 14.30, it must be submitted with the Annual Report in the
same envelope.
6. Pursuant to Section 9.20 of the Illinois Business Corporation Act, paid-in capital may be reduced without cancellation of shares only
through dividends paid on preferred shares, distributions as liquidating dividends or pursuant to an approved reorganization in bank-
ruptcy that specifically directs the reduction to be effected.
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