Foreign Professional Limited Liability Company Annual Report

FP The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Room 1717, Boston, Massachusetts 02108-1512 Foreign Professional Limited Liability Company Annual Report (General Laws Chapter 156C, Section 48) Federal Identification No.: _____________________________ (1a) The exact name of the foreign limited liability company: ________________________________________________________________________________________________ (1b) The exact name of the limited liability company as amended:* ________________________________________________________________________________________________ (1c) If different, the name under which it does business in the Commonwealth: ________________________________________________________________________________________________ (2) The jurisdiction where the limited liability company is organized and the date of organization: ________________________________________________________________________________________________ (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: Year: ____________________ (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) The business address of its principal office: * If the name of the limited liability company has been amended, attach a certificate evidencing the change issued by an officer or agency properly authorized in home state. American LegalNet, Inc. www.FormsWorkFlow.com (5) The business address of its principal office in the Commonwealth, if any : (6) The name and business address, if different from principal office address, of each manager, if any, and if none, so state: (7) The name and business address of each person authorized to execute, acknowledge, deliver and record any recordable instrument purporting to affect an interest in real property recorded with a registry of deeds or district office of the land court: NAME ADDRESS (8) The name and street address of the resident agent in the Commonwealth: (9) The latest date of dissolution (if any): ___________________________________________________________________ (10) 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 Foreign Professional Limited Liability Company Annual Report (General Laws Chapter 156C, Section 48) I hereby certify that upon examination of this foreign 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. c156cs48fpllcannual 10/14/08 American LegalNet, Inc. www.FormsWorkFlow.com