Free c156as18c156ds1622 - Massachusetts

PC FPC

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 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 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, shareholders, 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: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Shareholders (with residential address): _________________________________________________________________________________ (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 Professional and Foreign Professional 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) It is hereby certified, pursuant to G.L. Chapter 156A, Section 18, that the shareholders, and all the partners of a general partnership which is a shareholder 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 officer ® Court appointed fiduciary on this ____________________________________ day of _______________________________________________ , _________________ .
c156as18c156ds1622 01/13/05