Massachusetts Corporation Annual Report - Secretary Of Commonwealth

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The Commonwealth of Massachusetts
Fee $125.00
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place, Boston, Massachusetts 02108-1512
Telephone: (617) 727-9640
NOTE: PLEASE TYPE OR PRINT CLEARLY! INSTRUCTIONS ON OTHER SIDE.
MASSACHUSETTS CORPORATION ANNUAL REPORT
Federal Identification No.
REQUIRED
exact corporation name
1. The exact name of the corporation is:
number and street (no P.O. box)
2. Location of its principal office in Massachusetts
state
zip
city or town
NOTE: If corporation is organized wholly to do business outside Massachusetts, state location of that office also:
state
zip
number and street
city or town
if clerk out of state
3. Name and address of the Resident Agent, if any:
state
zip
number and street
city or town
month
day
year
4. Date of the end of the last fiscal year was:
5. Check here if the corporation stock is publicly traded:
6. The capital stock of each class as of the end of its last fiscal year was:
CLASS OF STOCK
PAR VALUE PER SHARE
TOTAL AUTHORIZED BY ARTICLES
TOTAL ISSUED
STATE IF NO PAR
OF ORGANIZATION OR AMENDMENTS
AND OUTSTANDING
Number of Shares
Total Par Value
Number of Shares
REQUIRED
REQUIRED
REQUIRED
COMMON:
PREFERRED:
7. State the names and addresses of the officers specified below and of all the directors of the corporation, and the date on which the
term of office of each expires:
OFFICERS
NAME
ADDRESS
EXPIRATION
Number, Street, City or Town, State, Zip Code
OF TERM
REQUIRED
no P.O. box
REQUIRED
PRESIDENT
REQUIRED
no P.O. box
TREASURER
REQUIRED
no P.O. box
CLERK
REQUIRED
no P.O. box
DIRECTORS
I, the undersigned,
REQUIRED
, being the
REQUIRED
of the
above-named corporation, in compliance with the General Laws, Chapter 156B, hereby certify that the above information is true and
correct as of the dates shown. IN WITNESS WHEREOF AND UNDER PENALTIES OF PERJURY, I hereto sign my name on this
REQUIRED
day of
REQUIRED
, year.
Signature:
Title:
MUST BE ORIGINAL
Contact Person:
Contact Person Telephone #:

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