Form Pc Fpc - Annual Report For Professional And Foreign Professional Corporations

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Filing Fee: $125.00

Late Fee: $25.00

The Commonwealth of Massachusetts

FPC

William Francis Galvin

Secretary of the Commonwealth

One Ashburton Place - Room 1717, Boston, Massachusetts 02108-1512

Annual Report for Professional and

FORM MUST BE TYPED

Foreign Professional Corporations

(General Laws Chapter 156A, Section 18 and Chapter 156D, Section 16.22)

(1) Exact name of the corporation: _______________________________________________________________________________________

(2) Jurisdiction of incorporation: _________________________________________________________________________________________

(3) Street address of the corporation’s registered office in the commonwealth:

_______________________________________________________________________________________________________________

(number, street, city or town, state, zip code)

(4) Name of the registered agent at the registered office: _______________________________________________________________________

(5) Street address of the corporation’s principal office:

_______________________________________________________________________________________________________________

(number, street, city or town, state, zip code)

(6) Provide the names and addresses of the corporation’s board of directors, shareholders, and its president, treasurer, secretary, and if different, its

chief executive officer and chief financial officer.

NAME

ADDRESS

President: ________________________________________________________________________________________________________

Treasurer: ________________________________________________________________________________________________________

Secretary: ________________________________________________________________________________________________________

Chief Executive Officer: _____________________________________________________________________________________________

Chief Financial Officer: _____________________________________________________________________________________________

Directors: _______________________________________________________________________________________________________

_______________________________________________________________________________________________________________

Shareholders (with residential address): _________________________________________________________________________________

(7) Briefly describe the business of the corporation:

_______________________________________________________________________________________________________________

(8-9) 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

COMMON

PREFERRED

(10) Check if the stock of the corporation is publicly traded.

(11) Report is filed for fiscal year ending: ________________________ / ________________________ /_______________________________

(month)

(day)

(year)

It is hereby certified, pursuant to G.L. Chapter 156A, Section 18, that the shareholders, and all the partners of a general partnership which is a share-

holder of the corporation are duly licensed to render one or more professional services for which the corporation was organized, or are professional

corporations authorized to render such professional services, and that a copy of this report is being sent to the appropriate regulatory board.

Signed by: __________________________________________________________________________________________________________

Chairman of the board of directors

President

Other officer

Court appointed fiduciary

on this ____________________________________ day of _______________________________________________ , _________________ .

c156as18c156ds1622 10/26/09