Annual Report For Domestic And Foreign Corporations

Filing Fee: $125.00 Late Fee: $25.00D F The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 FORM MUST BE TYPED Annual Report for Domestic and Foreign Corporations (General Laws Chapter 156D, Section 16.22; 950 CMR 113.57) (1) Exact name of the corporation: _______________________________________________________________________________________ (2) Jurisdiction of incorporation: _________________________________________________________________________________________ (3) Street address of the corporations registered o ce in the commonwealth: _______________________________________________________________________________________________________________ (number, street, city or town, state, zip code) (4) Name of the registered agent at the registered o _______________________________________________________________________ ce:(5) Street address of the corporations principal o ce: _______________________________________________________________________________________________________________ (number, street, city or town, state, zip code) (6) Provide the names and addresses of the corporations board of directors and its president, treasurer, secrif di etarerent,y, and its chief executive o cer and chief ? nancial o cer. NAME ADDRESS President: ________________________________________________________________________________________________________ Treasurer: ________________________________________________________________________________________________________ Secretary: ________________________________________________________________________________________________________ Chief Executive O cer: _____________________________________________________________________________________________ Chief Financial O cer: _____________________________________________________________________________________________ Directors: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ (7) Brie? y describe the business of the corporation: _______________________________________________________________________________________________________________ (8-9) Capital stock of each class and series: CLASS OF STOCK TOTAL AUTHORIZED BY ARTICLES OF ORGANIZA- TOTAL ISSUED AND OUTSTANDING TION OR AMENDMENTS Number of Shares Number of Shares COMMON PREFERRED (10) Check if the stock of the corporation is publicly traded. (11) Report is ? led for ? scal year ending: ________________________/ _________________________/ _____________________________ (month) (day) (year) Signed by: __________________________________________________________________________________________________________ Chairman of the board of directors President Other o cer Court-appointed ? duciaryon this ______________________________day ofday ofday of __________________________________________________________________________________________, __________________________. c156ds1622950c11357 01/13/05 American LegalNet, Inc. www.USCourtForms.com