Form Of Annual Return And Revenue Statement (Combo Return) For Calendar Year Ending December 31 (Page 3 of 4) in pdf

Form Of Annual Return And Revenue Statement (Combo Return) For Calendar Year Ending December 31 Page 3

If signatures of the above two parties were affixed outside of the Commonwealth of

Massachusetts, they must be properly sworn to, in person, as attested to by a Notary

Public or Justice of the Peace:

___________________________________

_____________________________________

Signature

Address (city, state and Zip Code)

___________________________________

My commission expires on: _____________

Name (typed or printed)

mm/yyyy

Revenue Statement

1. Exact legal name of reporting company ______________________________________________________

2. dba in MA, if any ________________________________________________________________________

3. Federal Employee Identification Number (FEIN) _______________________________________________

4. If filing a combined revenue statement, list registered name and FINs of all joint filers:

Registered name(s)

dba

FIN

________________________________________________________________________________________

5. MA intrastate operating revenue $ ___________________________________________________________

6. MA intrastate operating expenses $ ___________________________________________________________

CONTACT INFORMATION

Questions concerning the information provided in this return, and regulatory assessments

should be directed to:

[

] Please check if the contact information has changed since last filing.

Contact person/title

___________________________________________________________________________

Address

_____________________________________________________________________________________

Contact person telephone number ___________________ Contact person E-mail address

___________________

Form Of Annual Return And Revenue Statement (Combo Return) For Calendar Year Ending December 31 Page 3