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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 SUBMITINDUPLICATE
501 S. Second St., Rm. 351 Type or print clearly.
Springfield, IL 62756
217-524-8008
www.cyberdriveillinois.com
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
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