Application For Registration Renewal Or Cancellation Of Foreign Corp Name Under General Not For Profit Corporation Act {NFP-104.25}

FORM NFP 104.25 (rev. Aug. 2014) APPLICATION FOR REGISTRATION, RENEWAL OR CANCELLATION OF FOREIGN CORPORATION NAME General Not For Profit Corporation Act Secretary of State Department of Business Services 501 S. Second St., Rm. 350 Springfield, IL 62756 217-782-9520 217-782-6961 www.cyberdriveillinois.com Print Reset Save Payment must be made by check or money order payable to Secretary of State. Filing fee $ _________________________ File # ___________________________ Approved: _________________ 1. Corporate Name: ________________________________________________________________________________ -------- Submit in duplicate -------- Type or Print clearly in black ink -------- Do not write above this line -------- 2. State or Country of Incorporation: ___________________________________________________________________ 3. Date of Incorporation:_____________________________________________________________________________ 4. Affairs the Corporation is conducting: ________________________________________________________________ 5. Post Office Address of the corporation to which the Secretary of State may mail notices: ______________________________________________________________________________________________ ______________________________________________________________________________________________ 6. The corporation desires to register its corporate name pursuant to Section 104.25, and it is not conducting affairs in the State of Illinois at this time. 7. Attached to this application is a certificate setting forth that the corporation is in good standing under the laws of the State or Country wherein it is organized, executed by the proper officer of the State of Country wherein it is organized, which certificate shall not be more than 90 days old. 8. Check appropriate box: n Registration fee -- $50 n Renewal fee -- $50 n Cancellation fee -- $5 11. 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 Any Authorized Officer's Signature Name and Title (type or print) 10. A cancellation shall be effective upon filing with the Secretary of State. 9. Such registration shall be effective from the date of filing by the Secretary of State until the first day of the 12th month following such date. A renewal shall extend the registration 12 months. ______________________________________ ______________________________________ ________________________________________________ Exact Name of Corporation Printed by authority of the State of Illinois. January 2015 - 1 - C 223.9 American LegalNet, Inc. www.FormsWorkFlow.com