Form 630 - Profit Corporation Annual Report For The Year

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STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS
Office of the Secretary of State - Division of Business Services
148 W. River Street, Providence, Rhode Island 02904-2615
Phone: (401) 222-3040 ~ Email: corporations@sos.ri.gov ~ Website:
PROFIT CORPORATION ANNUAL REPORT FOR THE YEAR ________________
Filing Period: January 1 - March 1 • This report must be typed or printed legibly.
Filing Fee: $50.00 • FAILURE TO FILE THIS REPORT BY MARCH 31 WILL RESULT IN A $25.00 PENALTY FEE.
1. Entity ID No.
2. Exact name of the Corporation
3. Principal office address
City
State
Zip
4. Business Phone No.
5. State of Incorporation
6. Brief description of the character of business conducted in Rhode Island
7. LIST ALL OFFICERS (NAMES AND ADDRESSES) (“X” BOX FOR ATTACHMENT)
President Name
Vice-President Name
Street Address
Street Address
City
State
Zip
City
State
Zip
Secretary Name
Treasurer Name
Street Address
Street Address
City
State
Zip
City
State
Zip
8. LIST ALL DIRECTORS (NAMES AND ADDRESSES) (“X” BOX FOR ATTACHMENT)
Director Name
Director Name
Street Address
Street Address
City
State
Zip
City
State
Zip
Director Name
Director Name
Street Address
Street Address
City
State
Zip
City
State
Zip
9. SHARES AUTHORIZED
10. SHARES ISSUED (“X” BOX FOR ATTACHMENT)
NUMBER OF SHARES
CLASS/SERIES
PAR VALUE
This information is currently of record in the Office of the Secretary
of State. Changes require an additional filing.
See Section 9 of instruction sheet.
This report must be executed on behalf of the corporation by an authorized representative. If the corporation is in the hands of a receiver or trustee,
this report must be executed on behalf of the corporation by the receiver or trustee.
Under penalty of perjury, I declare and affirm that I have examined
this report, including any accompanying schedules and statements,
File Date ________________________
and that all statements contained herein are true and correct.
Check No _______________________
__________________________________________________________
By: ____________________________
Signature of Authorized Representative
Date
FOR SECRETARY OF STATE USE ONLY
__________________________________________________________
Print or Type Name of Authorized Representative
Form No. 630
Revised: 01/2012

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