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FORM BCA 14.05 DOMESTIC CORPORATION ANNUAL REPORT Business Corporation Act Secretary of State Department of Business Services 501 S. Second St., Rm. 350 Springfield, IL 62756 217-782-7808 ilsos.gov Payment must be made by check or money order payable to Secretary of State. File Prior To: ___________ Year: ________ File#: ___________ Approved: ____ _ Note: A change in the Registered Agent and/or Registered Office may OJJ4l be affected by filing form BCA-5.10/5.20. 1. Corporate Name: Registered Agent: Registered Office: City, IL, ZIP Code: County: 1 a. Is this corporation a publicly held corporation with outstanding shares listed on a major U.S. stock exchange and has its principal executive office located in Illinois, as defined by Section 8.12? □ YES □ NO If yes, form BCA 8.12 must be completed. 1 b. Is this corporation required to file form EEO-1? □ YES □ NO If yes, Workforce Demographic Data portion of the EEO-1 form must be attached. FAILURE TO COMPLETE 1 a and 1 b WILL CAUSE THE REPORT TO BE RETURNED. 2. Principal Address of Corporation·---------------------------------- Street City State ZIP Code 3. Date Incorporated:, _______________ _ Month Day Year 4. Names and addresses of officers and directors: NOTE: The names and addresses of ALL officers and directors must be entered in this item or on an additional sheet. OFFICE NAME NUMBER & STREET CITY STATE ZIP President Secretary Treasurer Director Director Director 5. If 51 % or more of stock is owned by a minority or female, please check appropriate box: □ Minority Owned □ Female Owned 6. Number of shares authorized and issued (as of ___________ ): CLASS SERIES PAR VALUE NUMBER AUTHORIZED NUMBER ISSUED IMPORTANT: If the amount in item 6 or 7a differs from the Secretary of State's records, form BCA 14.30 must be completed. 7a. Amount of Paid-in Capital (as of _______________ }: $ _________________ _ 7b. Paid-in Capital on record with Secretary of State:$ ___________________________ _ (Paid-in C apital reflects the sum of the S tated C apital and Paid-in surplus accounts.) Under the penalty of perjury and as an authorized officer, I declare that this annual report, 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. Item 8 Must Be Signed. 8. By: Any authorized officer's signature Title Date Please complete reverse side of this report. Printed by authority of the S tate of Illinois by union employees. January 2024 - 1 - C 289.21
