D F
Filing Fee: $125.00
Late Fee: $25.00
The Commonwealth of Massachusetts
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place, Boston, Massachusetts 02108-1512
Annual Report for Domestic
FORM MUST BE TYPED
FORM MUST BE TYPED
and Foreign Corporations
(General Laws Chapter 156D, Section 16.22; 950 CMR 113.57)
(1) Exact name of the corporation: _______________________________________________________________________________________
(2) Jurisdiction of incorporation: _________________________________________________________________________________________
(3) Street address of the corporation’s registered offi ce in the commonwealth:
_______________________________________________________________________________________________________________
(number, street, city or town, state, zip code)
(4) Name of the registered agent at the registered offi ce: _______________________________________________________________________
(5) Street address of the corporation’s principal offi ce:
_______________________________________________________________________________________________________________
(number, street, city or town, state, zip code)
(6) Provide the names and addresses of the corporation’s board of directors and its president, treasurer, secretary, and if diff erent, its chief executive
offi cer and chief fi nancial offi cer.
NAME
ADDRESS
President: ________________________________________________________________________________________________________
Treasurer: ________________________________________________________________________________________________________
Secretary: ________________________________________________________________________________________________________
Chief Executive Offi cer: _____________________________________________________________________________________________
Chief Financial Offi cer: _____________________________________________________________________________________________
Directors: _______________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
(7) Briefl y describe the business of the corporation:
_______________________________________________________________________________________________________________
(8-9) Capital stock of each class and series:
CLASS OF STOCK
TOTAL AUTHORIZED BY ARTICLES OF ORGANIZA-
TOTAL ISSUED AND OUTSTANDING
TION OR AMENDMENTS
Number of Shares
Number of Shares
COMMON
PREFERRED
(10) Check if the stock of the corporation is publicly traded.
(11) Report is fi led for fi scal year ending: ________________________ / _________________________ / _____________________________
(month)
(day)
(year)
Signed by: __________________________________________________________________________________________________________
Chairman of the board of directors
President
Other offi cer
Court-appointed fi duciary
on this ______________________________ day of _____________________________________________
day of _____________________________________________
day of
, __________________________ .
c156ds1622950c11357 01/13/05