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Petition For Refund Or Review BCA-1.17 - Illinois
| Petition For Refund Or Review Form. This is a Illinois form and can be used in Corporation Secretary Of State . |
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Form BCA-1.17 (Rev. Jan. 2003) Secretary of State Department of Business Services Springfield, IL 62756 217-785-2237 or 217-785-6033 www.cyberdriveillinois.com Payment must be made by check or money order payable to Secretary of State. Petition for Refund or Review This space for use by Secretary of State. File #: SUBMIT IN DUPLICATE This space for use by Secretary of State. Date: Filing Fee: $5 Approved: 11. Corporate Name: _______________________________________________________________________________ 12. State or Country of Incorporation: __________________________________________________________________ 13. Nature of Claim: (Mark an "X" in one box only.) 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. April 2006 -- 5M -- C 198.8 American LegalNet, Inc. www.USCourtForms.com
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