Professional Limited Liability Company Annual Report

P The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Room 1717, Boston, Massachusetts 02108-1512 Professional Limited Liability Company Annual Report (General Laws Chapter 156C, Section 12) Federal Identification No.: _____________________________ (1a) The exact name of the limited liability company: ________________________________________________________________________________________________ (1b) The exact name of the limited liability company as amended: ________________________________________________________________________________________________ (2) The street address of the office in the commonwealth at which its records will be maintained: Year: ____________________ (3a) The professional service to be rendered: ________________________________________________________________________________________________ (3b) The name and address of each member or manager who will render a professional service in the Commonwealth: (3c) The limited liability company agrees that each member or manager who will render a service in the Commonwealth is duly licensed to provide the service and to abide by and be subject to any conditions or limitations established by any applicable regulating board including the provision of liability insurance required by M.G.L. c.156C § 65. (4) Latest date of dissolution, if specified: ___________________________________________________________________ (5) The name and street address of the resident agent in the commonwealth: American LegalNet, Inc. www.FormsWorkFlow.com (6) The name and business address of each manager, if any, and if none, so state: (7) The name and business address of the person(s) in addition to manager(s) authorized to execute documents filed with the Corporations Division, and at least one person shall be named if there are no managers: (8) The name and business address of the person(s) authorized to execute, acknowledge, deliver and record any recordable instrument purporting to affect an interest in real property. (9) Additional matters: Signed by (by at least one authorized signatory): ________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com COMMONWEALTH OF MASSACHUSETTS Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 William Francis Galvin Professional Limited Liability Company Annual Report (General Laws Chapter 156C, Section 12) I hereby certify that upon examination of this professional limited liability company annual report, duly submitted to me, it appears that the provisions of the General Laws relative thereto have been complied with, and I hereby approve said application; and the filing fee in the amount of $ ___ having been paid, said application is deemed to have been filed with me this ________________ day of ________________, 20 _____, at _______a.m./p.m. time WILLIAM FRANCIS GALVIN Secretary of the Commonwealth Filing fee: $500 TO BE FILLED IN BY LIMITED LIABILITY COMPANY Contact Information: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Telephone: ___________________________________________________ Email: ______________________________________________________ Upon filing, a copy of this filing will be available at www.sec.state.ma.us/cor. If the document is rejected, a copy of the rejection sheet and rejected document will be available in the rejected queue. c156cs12pllcannual 10/14/08 American LegalNet, Inc. www.FormsWorkFlow.com