FILING FOR MARCH 1, 2017
FEDERAL IDENTIFICATION
NO. _____________________
The Commonwealth of Massachusetts
William Francis Galvin
Secretary of the Commonwealth
One Ashburton Place, Boston, Massachusetts 02108-1512
TAX DISCLOSURE REPORT
Preferred Provider Companies
1. Exact name of preferred provider company: ________________________________________________________________________
2. Location, including street address, of the preferred provider company’s principal office: _______________________________________
____________________________________________________________________________________________________________
I, _________________________________________, the undersigned *Treasurer / *Assistant Treasurer, of the above-named
company, do hereby certify that all the information contained herein is true and correct as of the date shown below.
SIGNED UNDER THE PENALTIES OF PERJURY, this __________ day of________________________________ , 20 ___________.
__________________________________________________________________________________ , *Treasurer / *Assistant Treasurer
(signature)
TAX DISCLOSURE REPORT
Preferred Provider Companies
3. Tax year for which the report is filed: .............................................................................................................. _____________________
4. Gross receipts or sales: ................................................................................................................................... $ _____________________
5. Income taxable in Massachusetts: .................................................................................................................. $ _____________________
6. Total Massachusetts excise or tax due: ............................................................................................................ $ _____________________
7. Set forth the amount of each tax credit taken: ______________________________________________________________________
*Delete the inapplicable words.
Note: You may furnish supplemental information in accordance with M.G.L. Ch 62C, s.83(j) on separate 8
x 11 sheets of white bond paper.
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tdrppc 11/10/16