Limited Liability Company Annual Report

D The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Room 1717, Boston, Massachusetts 02108-1512 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: ________________________________________________________________________________________________ (2a) Location of its principal office: ________________________________________________________________________________________________ (2b) The street address of the office in the commonwealth at which its records will be maintained: Year: ____________________ (3) The general character of the business: ________________________________________________________________________________________________ (4) Latest date of dissolution, if specified: ___________________________________________________________________ (5) The name and street address of the resident agent in the commonwealth: (6) The name and business address of each manager, if any: (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): ________________________________________________________________ COMMONWEALTH OF MASSACHUSETTS Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 William Francis Galvin Limited Liability Company Annual Report (General Laws Chapter 156C, Section 12) I hereby certify that upon examination of this 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 Effective date: ____________________________________________________ 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. c156c512cdllcannual 01/07/14