Form Of Annual Return And Revenue Statement (Combo Return) For Calendar Year Ending December 31 (Page 2 of 4) in pdf

Form Of Annual Return And Revenue Statement (Combo Return) For Calendar Year Ending December 31 Page 2

Combo Annual Return and Revenue Statement of ______________________ for CY ending December 31, ______

Pag

e 2

9. Is this filing a combined return? [ ] No [ ] Yes

If ‘yes’ provide the following information:

Name(s) of joint filer(s)

FIN(s)

_________________________________________________________________________________

10. Date and state of incorporation ________________________________________________________

11. Long-term debt $ ________________________

Short-term debt $ ________________________

12. Capital stock authorized $ _________________

Capital stock outstanding $ ________________

13. Dividends paid out $ _____________________

Dividends declared $ _____________________

14. Briefly describe company’s business operations in MASSACHUSETTS.

_________________________________________________________________________________

Signature and Oath of Treasurer and Chief Accounting Officer

We hereby certify that all statements contained in this return are full, just and true on this,

the __________________day of ________________________, in the year ________________.

Treasurer:

___________________________________

_____________________________________

Name (typed or printed)

Signature

Chief Accounting Officer:

___________________________________

_____________________________________

Name (typed or printed)

Signature

Form Of Annual Return And Revenue Statement (Combo Return) For Calendar Year Ending December 31 Page 2