Free c156ds1622950c11357.indd - Massachusetts

DF

The Commonwealth of Massachusetts
William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512

Filing Fee: $125.00 Late Fee: $25.00

FORM MUST BE TYPED

(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 office in the commonwealth: _______________________________________________________________________________________________________________ (number, street, city or town, state, zip code) (4) Name of the registered agent at the registered office: _______________________________________________________________________ (5) Street address of the corporation's principal office: _______________________________________________________________________________________________________________ (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 officer and chief financial officer. NAME ADDRESS President: ________________________________________________________________________________________________________ Treasurer: ________________________________________________________________________________________________________ Secretary: ________________________________________________________________________________________________________ Chief Executive Officer: _____________________________________________________________________________________________ Chief Financial Officer: _____________________________________________________________________________________________ Directors: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ (7) Briefly 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

Annual Report for Domestic and Foreign Corporations

COMMON PREFERRED

(10) Check if the stock of the corporation is publicly traded. (11) Report is filed for fiscal year ending: ________________________ / _________________________ / _____________________________ (month) (day) (year) Signed by: __________________________________________________________________________________________________________ Chairman of the board of directors President Other officer Court-appointed fiduciary

on this ______________________________ day of _____________________________________________ , __________________________ .
c156ds1622950c11357 01/13/05