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STATE OF ILLINOIS
County of Kane
)
)
SS

Certificate No.

SUPPLEMENTARY CERTIFICATE OF OWNERSHIP OF BUSINESS

On the date of  , the original certificate of ownership was filed in the office of the County Clerk for:

NAME OF BUSINESS

The following changes are now indicated:

Addition of person(s) name Withdrawal of person(s) name
Change of Address Closing business

Please specify:

......................................................................

STATE OF ILLINOIS
County of Kane
)
)
SS

     ___________________________________________________, being duly sworn, upon oath deposes and says that the foregoing is a true and correct supplementary report of the person or persons who have ceased doing business in the above-named firm, together with their home addresses, or a change of addres of the business.
 

 

 

____________________________________
Signature of Informant


Subscribed and sowrn to before me this date: ______________________________________________


(notary seal)


____________________________________
Signature of Notary Public

NOTE: When withdrawal or addition effectuates change or transfer of 25% or more of total ownership, notice of filing Supplementary Certificate must be published.