Annual Report For Professional And Foreign Professional Corporations

Filing Fee: $125.00PC Late Fee: $25.00 The Commonwealth of Massachusetts William Francis Galvin FPC Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 FORM MUST BE TYPED Annual Report for Professional and 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 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, shareholders, and its president, treasurerif di , secr eretarent,y its , and chief executive o cer and chief ? nancial o cer. NAME ADDRESS President: ________________________________________________________________________________________________________ Treasurer: ________________________________________________________________________________________________________ Secretary: ________________________________________________________________________________________________________ Chief Executive O cer: _____________________________________________________________________________________________ Chief Financial O cer: _____________________________________________________________________________________________ Directors: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Shareholders (with residential address): _________________________________________________________________________________ (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) It is hereby certi? ed, 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 o cer Court appointed ? duciary on this ____________________________________day ofday ofday of ______________________________________________________________________________________________, _________________. c156as18c156ds1622 01/13/05 American LegalNet, Inc. www.USCourtForms.com