FORM MUST BE TYPED
The Commonwealth of Massachusetts
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place - Room 1717, Boston, Massachusetts 02108-1512
c156ds1622950c11357 11/23/09
Filing Fee: $125.00
Late Fee: $25.00
D F
Annual Report for Domestic
and Foreign Corporations
(General Laws Chapter 156D, Section 16.22; 950 CMR 113.57)
(1) Exact name of the corporation:
(2) Jurisdiction of incorporation:
(3) Street address of the corporation’s registered oce in the commonwealth (number, street, city or town, state, zip code):
(4) Name of the registered agent at the registered oce:
(5) Street address of the corporation’s principal oce (number, street, city or town, state, zip code):
(6) Provide the names and addresses of the corporation’s board of directors and its president, treasurer, secretary, and if different, its chief executive
ocer and chief nancial ocer.
NAME ADDRESS
President:
Treasurer:
Secretary:
Chief Executive Ocer:
Chief Financial Ocer:
Directors:
(7) Briey describe the business of the corporation:
(8-9) Capital stock of each class and series:
CLASS OF STOCK TOTAL AUTHORIZED BY ARTICLES OF
ORGANIZATION OR AMENDMENTS
Number of Shares
TOTAL ISSUED AND OUTSTANDING
Number of Shares
COMMON
PREFERRED
(10) Check if the stock of the corporation is publicly traded.
(11) Report is led for scal year ending: ________________________ / _________________________ / _____________________________
(month) (day) (year)
Signed by: __________________________________________________________________________________________________________
Chairman of the board of directors President Other ocer Court-appointed duciary
on this ______________________________ day of _____________________________________________ , __________________________ .
