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  5. FORM AND ACTION, LLC

FORM AND ACTION, LLC

Company Details

Entity Name: FORM AND ACTION, LLC
Jurisdiction: Illinois
Entity Type: Limited Liability Company
Status: Voluntary Diss./Terminated
Date Formed: 28 May 2003
Company Number: LLC_00928127
File Number: 00928127
Type of Management: Member Managed
Date Status Change: 30 Apr 2008
Expiration Date: 28 May 2033
Address 416 S. 9TH ST., ST. CHARLES, 60174, IL
Place of Formation: ILLINOIS

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
DERMASSOCIATES, LTD PROFIT SHARING PLAN 2011 371003203 2012-07-19 DERMASSOCIATES, LTD 12
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1976-04-01
Business code 446190
Sponsor’s telephone number 6182773614
Plan sponsor’s address 3608 W. MAIN STREET, BELLEVILLE, IL, 62223

Plan administrator’s name and address
Administrator’s EIN 371003203
Plan administrator’s name DERMASSOCIATES, LTD
Plan administrator’s address 3608 W. MAIN STREET, BELLEVILLE, IL, 62223
Administrator’s telephone number 6182773614

Signature of
Role Plan administrator
Date 2012-07-19
Name of individual signing JERRY AKIN
Valid signature Filed with authorized/valid electronic signature
DERMASSOCIATES, LTD PROFIT SHARING PLAN 2010 371003203 2011-07-06 DERMASSOCIATES, LTD 10
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1976-04-01
Business code 446190
Sponsor’s telephone number 6182773614
Plan sponsor’s address 3608 W. MAIN STREET, BELLEVILLE, IL, 62223

Plan administrator’s name and address
Administrator’s EIN 371003203
Plan administrator’s name DERMASSOCIATES, LTD
Plan administrator’s address 3608 W. MAIN STREET, BELLEVILLE, IL, 62223
Administrator’s telephone number 6182773614

Signature of
Role Plan administrator
Date 2011-07-06
Name of individual signing JERRY AKIN
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2011-07-06
Name of individual signing JERRY AKIN
Valid signature Filed with authorized/valid electronic signature
DERMASSOCIATES, LTD PROFIT SHARING PLAN 2010 371003203 2011-07-06 DERMASSOCIATES, LTD 10
Three-digit plan number (PN) 001
Effective date of plan 1976-04-01
Business code 446190
Sponsor’s telephone number 6182773614
Plan sponsor’s address 3608 W. MAIN STREET, BELLEVILLE, IL, 62223

Plan administrator’s name and address
Administrator’s EIN 371003203
Plan administrator’s name DERMASSOCIATES, LTD
Plan administrator’s address 3608 W. MAIN STREET, BELLEVILLE, IL, 62223
Administrator’s telephone number 6182773614

Signature of
Role Plan administrator
Date 2011-07-06
Name of individual signing JERRY AKIN
Valid signature Filed with authorized/valid electronic signature
DERMASSOCIATES, LTD PROFIT SHARING PLAN 2010 371003203 2011-07-06 DERMASSOCIATES, LTD 10
Three-digit plan number (PN) 001
Effective date of plan 1976-04-01
Business code 446190
Sponsor’s telephone number 6182773614
Plan sponsor’s address 3608 W. MAIN STREET, BELLEVILLE, IL, 62223

Plan administrator’s name and address
Administrator’s EIN 371003203
Plan administrator’s name DERMASSOCIATES, LTD
Plan administrator’s address 3608 W. MAIN STREET, BELLEVILLE, IL, 62223
Administrator’s telephone number 6182773614
DERMASSOCIATES, LTD PROFIT SHARING PLAN 2009 371003203 2010-08-10 DERMASSOCIATES, LTD 9
File View Page
Three-digit plan number (PN) 001
Effective date of plan 1976-04-01
Business code 446190
Sponsor’s telephone number 6182773614
Plan sponsor’s address 3608 W. MAIN STREET, BELLEVILLE, IL, 62223

Plan administrator’s name and address
Administrator’s EIN 371003203
Plan administrator’s name DERMASSOCIATES, LTD
Plan administrator’s address 3608 W. MAIN STREET, BELLEVILLE, IL, 62223
Administrator’s telephone number 6182773614

Signature of
Role Plan administrator
Date 2010-08-10
Name of individual signing JERRY AKIN
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2010-08-10
Name of individual signing JERRY AKIN
Valid signature Filed with authorized/valid electronic signature

Agent

Name and Address Role Appointment Date
TIMOFEI B. BOLSHAKOV, 416 S. 9TH ST., ST. CHARLES, 60174, KANE Agent 2005-05-13

Member

Name and Address Role Appointment Date
BOLSHAKOVA, EKATERINA A., 416 S 9TH ST, ST CHARLES, IL, 60174 Member 2003-05-28
BOLSHAKOV, TIMOFEI B., 416 S 9TH ST, ST CHARLES, IL, 60174 Member 2003-05-28

Related by officers

No related officers

Related by address

No related companies by address

Date of last update: 16 Jan 2025

Sources: Illinois Office of the Secretary of State

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