Annual Report - Secretary Of The Commonwealth
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The Commonwealth of Massachusetts
M.G.L. Ch.180
William Francis Galvin
Corporation
Secretary of the Commonwealth
One Ashburton Place, Boston, Massachusetts 02108-1512
Annual Report
Telephone: (617) 727-9640
ANNUAL REPORT
FEDERAL IDENTIFICATION
Filing for November 1, 19 __________
NO. _____________________
In compliance with the requirements of Section 26A of Chapter one hundred and eighty (180) of the General Laws:
1. NAME: __________________________________________________________________________________________________
2. ADDRESS: _______________________________________________________________________________________________
(number)
(street)
__________________________________________________________________________________________________________
(city or town)
(state)
(zip)
3. DATE OF THE LAST ANNUAL MEETING: _____________________________________________________________________
4. State the names and addresses of all officers,including all the directors of the corporation, and the date on which the term
of office of each expires: (PLEASE TYPE OR PRINT).
NAME OF OFFICE
NAME
ADDRESSES
EXPIRATION
Number, Street, City or Town,
OF TERM OF
State and Zip Code
OFFICE
President:
Treasurer:
Clerk:
(or Secretary)
Directors:
(or Officers
having the
powers of
Directors)
I, the undersigned _______________________________________ being the _________________________ of the above-named
corporation, in compliance with General Laws, Chapter 180, hereby certify that the information above is true and correct as
of the dates shown.
IN WITNESS WHEREOF AND UNDER PENALTIES OF PERJURY, I hereto sign my name on this __________________________
day of _____________________________________ , 19 ______ .
Signature: ____________________________________________ Title: ________________________________________________
Contact Person: _______________________________________ Contact Person Telephone #: ___________________________
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