FORM MUST BE TYPED
The Commonwealth of Massachusetts
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place - Room 1717, Boston, Massachusetts 02108-1512
c156as18c156ds1622 10/26/09
PC
FPC
Filing Fee: $125.00
Late Fee: $25.00
Annual Report for Professional and
Foreign Professional Corporations
(General Laws Chapter 156A, Section 18 and Chapter 156D, Section 16.22)
(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, shareholders, 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: _______________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Shareholders (with residential address): _________________________________________________________________________________
(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)
It is hereby certied, pursuant to G.L. Chapter 156A, Section 18, that the shareholders, and all the partners of a general partnership which is a share-
holder of the corporation are duly licensed to render one or more professional services for which the corporation was organized, or are professional
corporations authorized to render such professional services, and that a copy of this report is being sent to the appropriate regulatory board.
Signed by: __________________________________________________________________________________________________________
Chairman of the board of directors President Other ocer Court appointed duciary
on this ____________________________________ day of _______________________________________________ , _________________ .
