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FORM BCA-1.17(rev. Dec. 2014)
P etition for Refund or Review
Business Corporation Act
Department of Business Services
501 S. Second St., Rm. 350
Springfield, IL  62756
217-782-6961
www.cyberdriveillinois.com
Payment must be made by check or money 
o rder 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 o
                                                             Refund          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