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FORM BCA-14.01(rev. May 2015)
STATEMENT OF ELECTION TO 
ESTABLISH AN EXTENDED 
FILING MONTH
Business Corporation Act
Department of Business Services
501 S. Second St., Rm. 350
Springfield, IL  62756
217-782-6961
www.cyberdriveillinois.com
P ayment must be made by check or money 
order payable to Secretary of State. 

        Filing Fee: $25              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/Qualified:___________________________________________________________________

4.   Date of fiscal year end immediately preceding this election: __________________________________________

5.   Extended filing month (See Note 2.): ____________________________________________________________

6.   This Statement of Election is accompanied by an Interim Annual Report, which shall set forth, as of the date of 
     filing of the statement, all of the information required pursuant to Section 14.05 of the Business Corporation Act 
     to be included in the annual report, except that the information required by subparagraph (h) of Section 14.05 
     shall be the amounts represented in this state as disclosed by the preceding annual report, or, if no annual report
     is on file, from information contained in the articles of incorporation of a domestic corporation or the application 
     for authority in the case of a foreign corporation.

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.

Dated:  _________________________ ,  ____________        ____________________________________________
            Month  Day                              Year               (Exact Name of Corporation)
by:  _______________________________________
            (Any authorized Officer’s signature)
     _______________________________________
                      (Type or Print Name and Title)

                                                         IMPORTANT!

FOR A CORPORATION SEEKING TO ESTABLISH AN EXTENDED FILING MONTH, SECTION 14.01 OF THE BUSINESS
CORPORATION ACT REQUIRES THIS DOCUMENT BE FILED PRIOR TO THE FIRST DAY OF THE CORPORATION'S
ANNIVERSARY MONTH.

                                     Printed by authority of the State of Illinois. May 2015 - 1 - C 242.8

                                                   NOTES

Note 1:
Each domestic corporation and each foreign corporation authorized to transact business in this state, having reported
on its last annual report or if no annual report  is on file, on the articles of incorporation of a domestic corporationor on the
application for authority of a foreign corporation, an amount less than 100 percent of its paid-in capital represented in
Illinois, may make anirrevocable, one time electionto establish an extended  filing month for the purpose of filing annual
reports for all subsequent taxable years.

Note 2:
The extended filing month may be any month in that is one of the nine months consecutively following the end of
the corporation's fiscal year, except that the extended filing month may not be one of the two months immediately preceding
the corporation's anniversary month. 

Notwithstanding the foregoing, a corporation whose fiscal year ends within the two months immediately preceding
its anniversary month may notelect an extended filing month.

Note 3:
When filing an Interim Annual Report DO NOTcomplete items 9 or 10. In calculating the interim annual franchise
tax, the corporation must use the factor established from its last annual report or, if no annual report is on file, on the articles
of incorporation of a domestic corporation or on the application for authority of a foreign corporation. This factor appears
beneath the checklist on the preprinted annual report recently mailed to the corporation.

Form BCA 14.05-I                           STATE OF ILLINOIS                 YEAR OF _______  File #

                                           DOMESTIC/FOREIGN CORPORATION
                                           INTERIM ANNUAL REPORT

                             Please Type or Print Clearly in Black Ink

1.   CORPORATE NAME
     R EGISTERED AGENT
     REGISTERED OFFICE
     CITY, IL, ZIP CODE

2.   (a)  Date of Incorporated/Qualified:         ________________

     (b)  State or Country of Incorporation: ________________

3.   (a)  Give complete address of principal office,
         if other than above.

         _____________________________________________

         _____________________________________________

3.   (b)  FEIN No.:  ____________________________________

4.   Names and addresses of the officers and directors (If officers are directors, so state.):
                 Name                             Number & Street            City             State         ZIP
     President
     Secretary
     Treasurer
     Director
     Director
     Director

5.   Type of business actually conducted in Illinois: _______________________________________________

6.   Authorized and issued shares as of ____________________ :
                                                     (Date)
     Class       Series                    Par Value                  Number Authorized       Number issued

7.   (a)  Paid-in capital as of___________________ :    (b)  Paid-in Capital as of ________________________ ,
                                           (Date)                                             (Date)
           PAID-IN CAPITAL $ __________________                       on record with the Secretary of State:
           ("Paid-in Capital" replaces the terms "Stated Capital" and        TOTAL $ _____________________________
           "Paid-in Surplus." It does not include Retained Earnings.)
     (x)   Previous Allocation Factor: ____________________

                                           ITEM 8 MUST BE SIGNED
8.        By: ___________________________________________________________________________________
         (Authorized Officers's Signature)                           (Title)                  (Date)  
Under penalty of perjury and as an authorized officer, I declare that this annual report and, if applicable, the statement of change of
registered agent and/or office, 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.

9.  Omitted

10. Omitted

11. INTERIM ANNUAL FRANCHISE TAX AND FEES

    (a.)     Total Paid-in Capital (Enter the GREATER of item 7a or item 7b
            from other side of this annual report form) . . . . . . . . . . . . . . . . . . . . . . . . .                                   a

            (b.)      ALLOCATION FACTOR (Enter from item 7x from other side
            of this annual report) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                        b

            (c.)      ILLINOIS CAPITAL (Multiply line (a) by line (b).) . . . . . . . . . . . . . . . . . . . .            c

            (d1.)    Illinois Capital (Enter from line (c).) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .d1 

            (d2.)    Multiply line (d1) by .001 (Round to nearest cent.) . . . . . . . . . . . . . . . . . .d2

            (d3.)    ANNUAL FRANCHISE TAX (Enter amount from line (d2),  but not less than $25.) . . . . . .d3

            (e.)      If Interim Annual Report is late, multiply line (d3) by .10 (Penalty) . . . . . . . . . . . . . . . . . . .            e

            (f.)       If Interim Annual Franchise Tax is late, multiply line (e3) by .02 for each month
            or part thereof late (minimum $1.00) (Interest) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                f

            (g.)      ANNUAL REPORT FILING FEE  ($75) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .+75.00     g

            (h.)      TOTAL ANNUAL FRANCHISE TAX, FEES & PENALTIES DUE
            (Add line d3 + line e + line f + line g.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .         h

12. Section 14.01 of the Business Corporation Act requires that this document must be submitted with the Statement
    of Election to Establish an Extended Filing Month and the required $25 filling fee.

           ITEM 8 MUST BE SIGNED

REMIT CHECK OR MONEY ORDER, PAYABLE TO "SECRETARY OF STATE," IN THE TOTAL AMOUNT DUE LISTED ON LINE
11h. THIS FEE MUST BE SUBMITTED WITH THIS ANNUAL REPORT FORM!  IF THE PROPER REMITTANCE IS NOT
ENCLOSED, THIS REPORT WILL NOT BE ACCEPTED FOR FILING, AND A LATE PENALTY MAY BE ASSESSED.

           Your cancelled check is your receipt. 

           IMPORTANT!

           THIS FORM MAY ONLY BE USED IN CONNECTION WITH FORM BCA-14.01 
           AND MAY NOT BE SUBMITTED INDEPENDENTLY.