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                                                    Illinois                                                     FILE #
Form LLC-5.48                         Limited Liability Company Act                                              This space for use by Secretary of State.
July 2017
Secretary of State                    Petition for Refund
Department of Business Services 
Limited Liability Division                     SUBMIT IN DUPLICATE   
501 S. Second St., Rm. 351                        Type or print clearly.
Springfield, IL  62756
217-524-8008
www.ilsos.gov
                                      Filing Fee: $5
Payment  may  be  made  by  check     Approved:
payable  to  Secretary  of  State.  If
check  is  returned  for  any  reason
this filing will be void.

1. Limited Liability Company name: ______________________________________________     _____________________

2. State or country of organization: ___________________________________________________________________

3. Amount of claim:________________________________________________________________________________
No refund shall be made for an overpayment of less than $200.
Any amount to be refunded shall be reduced by $200.

4. Details of transaction and all facts upon which the petitioner relies: ________________________________________
(If there is not sufficient space to cover this point, attach additional sheets of this size.)

5. I affirm, under the penalties of perjury, having the authority to sign hereto, that this Petition for Refund is to the best of
my knowledge and belief, true, correct and complete.

                                                             Date: _________________________, ___________
                                                                        Month/Day                                         Year

                                                                        ________________________________________
                                                                                                                 Signature

                                                                        ________________________________________
                                                                        Name and Title (type or print)

                                                                        ________________________________________
                                                                        If applicant is signing for a company or other entity, 
                                                                        state name of company. 

                                      Printed by authority of the State of Illinois. December 2017 — 1 — LLC 35.6