Form D - Annual Report For Domestic And Foreign Corporations - The Commonwealth Of Massachusetts
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1D 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
and Foreign Corporations
FORM MUST BE TYPED
(General Laws Chapter 156D Section 16.22; 950 CMR 133.56)
(1) Th e exact name of the corporation is __________________________________________________________________________________ .
(2) Th e corporation is organized under the laws of __________________________________________________________________________
(2) Th e corporation is organized under the laws of __________________________________________________________________________
(2) Th e corporation is organized under the laws of
.
(3) Th e street address of the corporation’s registered offi ce in the commonwealth is:
______________________________________________________________________________________________________________ .
(number, street, city or town, state, zip code)
(4) Th e name of the registered agent at the registered offi ce is __________________________________________________________________ .
(5) Th e street address of the corporation’s principal offi ce is:
______________________________________________________________________________________________________________ .
(number, street, city or town, state, zip code)
(6) Provide the name and business addresses of the corporation’s board of directors and its president, treasurer and 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) Th e capital stock of each class and series
CLASS OF STOCK
TOTAL AUTHORIZED BY ARTICLES OF
TOTAL ISSUED AND OUTSTANDING
ORGANIZATION OR AMENDMENTS
Number of Shares
Number of Shares Total Par Value
COMMON:
PREFERRED
(10) Check if the stock of the corporation is publicly traded.
(11) Date of the fi scal year end is ________________________________________________________________________________________ .
(month, day, year)
Signed by __________________________________________________________________________________________________________
Signed by __________________________________________________________________________________________________________
Signed by
,
(signature of authorized individual)
(
Please check appropriate box)
Chairman of the Board of Directors
Incorporator
Other Offi cer
Court Appointed Fiduciary
on this ______________________________ day of ____________________________________________
day of ____________________________________________
day of
of __________________________
of __________________________
of
.
156d1622 9/23/04
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