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Cumulative Report Of Changes In Issued Shares And Paid-In Capital BCA-14.30 - Illinois

Cumulative Report Of Changes In Issued Shares And Paid-In Capital Form. This is a Illinois form and can be used in Corporation Secretary Of State .
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Form BCA-14.30 (Rev. Jan. 2003) Secretary of State Department of Business Services 501 S. Second St., Rm. 350 Springfield, IL 62756 217-782-9522, 217-782-6961 www.cyberdriveillinois.com File #: DO NOT SEND CASH Cumulative Report of Changes in Issued Shares and Paid-In Capital (Please type or print legibly in BLACK INK) Date: License Fee: Franchise Tax: Filing Fee: Penalty: Interest: Approved: $ $ $5 $ $ 1. Corporate Name: ________________________________________________________________________________ 2. State or Country of Incorporation: ___________________________________________________________________ 3. Authorized and Issued Shares as last reported (In any document other than an annual report.): Class Series Par Value Number Authorized Number Issued _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 4. Paid-in Capital as last reported (In any document other than an annual report.): $ _____________________________ 5. Current Reporting Period Transactions (See Note 1 on back.): · List the total issuances and exchanges of shares by class not previously reported to the Secretary of State. Also, give the value of the entire consideration received (less expenses paid or incurred in connection with such issuances) and added or transferred to paid-in capital for or on account of such shares. · List the total amount added or transferred to paid-in capital without the issuance of shares (contributions). · List the total of all cancellations of shares by class not previously reported to the Secretary of State and the cost to paid-in capital for acquiring such shares. · List the total amount subtracted from paid-in capital without a cancellation of shares, but as permitted by Section 9.20 of the Illinois Business Corporation Act (reductions). Class of Number of Consideration Shares Series Par Value Shares Received/Cost _________________________________________________________________________________________________ Issuance or Contributions: $ $ $ $ $( $( $( $ ) ) ) Cancellations or Reductions: (State reason for reduction if no shares were cancelled. See Note 6 on back.) Cumulative Change (Enter on line 6a below. See Note 2 on back.): 6. Franchise Tax and Fees (No additional franchise tax is due when cumulative change is negative amount.): a. Cumulative Change....................................................................... a. b. Applicable Allocation Factor (See Note 3 on back.) ..................... b. c. Taxable Illinois Capital (Multiply line a by line b.) ......................... c. d. Multiply line c by .0015 (Round to nearest cent.) ......................... d. e. Additional Franchise Tax (Enter amount from line d.).......................................................... e. f. If Cumulative Report is late, multiply line e by .10 (penalty) ............................................... f. g. If Additional Franchise Tax is late, multiply line e by .02 for each month late or part thereof (interest) (minimum $1)................................................................................ g. 5.00 h. FILING FEE ($5) ........................................................................................... h. i. Total Amount Due (Add line e + line f + line g + line h.) ..................................................... i. COMPLETE BOTH SIDES OF THIS REPORT. Printed by authority of the State of Illinois. March 2008 - 8M - C 284.12 American LegalNet, Inc. www.FormsWorkflow.com 7. Transactions occurring during previous reporting period(s) and not reported to the Secretary of State (See Note 4 below.): The Secretary of State will compute fees, taxes and penalties resulting from the following transactions.) _________________________________________________________________________________________________ Issuance or $ Contributions: $ $ $ Cancellations or Reductions: (State reason for reduction if no shares were cancelled. See Note 6 below.) ITEMS 8 AND 9 MUST BE COMPLETED. 8. Authorized and Issued Shares after changes: Class Series Par Value Number Authorized Number Issued Date Class of Shares Series Par Value Number of Shares Consideration Received/Cost $( $( $( ) ) ) _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 9. Paid-In Capital after changes: $ ______________________________ ("Paid-In Capital" replaces the terms Stated Capital and Paid-In Surplus and is equal to the total of these accounts.) ITEM 10 MUST BE SIGNED. 10. 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 ______________________________________ Any Authorized Officer's Signature ______________________________________ Name and Title (type or print) NOTES 1. "Current reporting period" for a corporation that has not established an extended filing month means the 12-month period ending with the last day of the third month prior to its anniversary month in the current year. In the case of a corporation that has established an extended filing month, the "current reporting period" refers to the 12-month period ending with the corporation's most recent fiscal year end. 2. "Cumulative change" means the difference arrived at by subtracting all reductions as permitted by Section 9.20 of the Illinois Business Corporation Act in paid-in capital (if any) from all increases in paid-in capital (if any). However, a net reduction in paid-in capital reported on Form BCA 14.30 filed after
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