Form Of Annual Return And Revenue Statement (Combo Return) For Calendar Year Ending December 31 printable pdf download

Form Of Annual Return And Revenue Statement (Combo Return) For Calendar Year Ending December 31

COMMONWEALTH OF MASSACHUSETTS

DEPARTMENT OF TELECOMMUNICATIONS AND CABLE

TWO SOUTH STATION

BOSTON, MA 02110

(617) 305-3580

DANIEL O’CONNELL

DEVAL L. PATRICK

GOVERNOR

SECRETARY OF HOUSING AND

ECONOMIC DEVELOPMENT

TIMOTHY P. MURRAY

LIEUTENANT GOVERNOR

DANIEL C. CRANE

DIRECTOR OF CONSUMER AFFAIRS

AND BUSINESS REGULATION

SHARON E. GILLETT

COMMISSIONER

Annual Return and Revenue Statement (Combo Return)

for calendar year ending December 31, _________

1. Exact legal name of the registered company is _______________________________________

2. Doing business as (dba) in MA, if any _________________________________________________

3. Federal Employee Identification No. (FIN) ___________________________________________

4. Address of its principal office is ____________________________________________________

_______________________________________________________________________________

5. Address of its regulatory office, if different from principal office __________________________

______________________________________________________________________________

6. Mailing address, if different from above ______________________________________________

_______________________________________________________________________________

7. Main/General Telephone Number ___________________________________________________

8. Has company changed its registered and/or operating name(s) during the calendar year?

[ ]No [ ]Yes If ‘yes’ provide the following information:

Previous name(s)

dba

FIN

Date changed/reason

_________________________________________________________________________________

Form Of Annual Return And Revenue Statement (Combo Return) For Calendar Year Ending December 31