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Annual Report - Massachusetts

Annual Report Form. This is a Massachusetts form and can be used in Nonprofit Corporations Corporations Division Secretary Of State .
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FEE:$15.00 The Commonwealth of Massachusetts WilliamFrancisGalvin M.G.L. Ch.180 SecretaryoftheCommonwealth Corporation OneAshburtonPlace,Boston,Massachusetts02108-1512 Annual Report Telephone:(617)727-9640 ANNUALREPORT FEDERALIDENTIFICATION FilingforNovember1,20 ______________ NO.______________________ IncompliancewiththerequirementsofSection26AofChapteronehundredandeighty(180)oftheGeneralLaws: 1.NAME: ___________________________________________________________________________________________________ 2.ADDRESS:________________________________________________________________________________________________ (number) (street) ____________________________________________________________________________________________________________ (city or town) (state) (zip) 3. DATEOFTHELASTANNUALMEETING: _____________________________________________________________________ 4.Statethenamesandaddressesofallof?cers,includingallthedirectorsofthecorporation,andthedateonwhichthetermofof?ceof eachexpires:(PLEASETYPEORPRINT). 5.Ifthecorporationisacemeterycorporation,checkifitholdsperpetualcarefundsintrust. Attachacopyofthewritten instrumentestablishingthetrustandanyamendmentsthereto. NAMEOFOFFICENAMEOFOFFICENAMEOFOFFICENAMEOFOFFICENAMEOFOFFICENAMENAMENAMENAMENAME ADDRESSESADDRESSESADDRESSESADDRESSESADDRESSESEXPEXPEXPEXPEXPIRAIRAIRAIRAIRATIONTIONTIONTIONTION Number,Street,CityorTown, OFOFTERMOFTERMOF StateandZipCode OFFICEOFFICE President: Treasurer: Clerk: (orSecretary) Directors: (orOf?cers havingthe powersof Directors) I,theundersigned________________________________________beingthe____________________________oftheabove-named corporation,incompliancewithGeneralLaws,Chapter180,herebycertifythattheinformationaboveistrueandcorrectasofthedates shown. INWITNESSWHEREOFANDUNDERPENALTIESOFPERJURY,Iheretosignmynameonthis __________________________ dayofdayofdayof______________________________________________________________________________,20 ______ . Signature: ____________________________________________Title:________________________________________________ ContactPerson:_________________________________________ContactPersonTelephone#:______________________________ 180npcar 8/31/04 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2INSTRUCTIONS: PLEASETYPEORPRINTCLEARLYASDOCUMENTWILL BEMICROFILMEDANDCLARITYISIMPORTANT. NOTE:INSERT FEDERALFEDERALFEDERALIDENTIFICAIDENTIFICATIONNUMBER(EMPLTIONNUMBER(EMPLOYERSI.D.).IFOYERSI.D.).IFYOUDONOYOUDONOTHAVEONETHAYOUMUSTVEONE YOUMUST APPLYTOTHEINTERNALREVENUESERVICE. Line1. InserttheEXACTnameofthecorporationasitappearsontheArticlesofOrganizationorsubsequent amendments.Donotuseanyd/b/anames,tradenames,orabbreviations. Line2. Statephysicalcorporateaddresswithnumberandstreet,cityortown,stateandzipcode. Line3. Insertthemonth,day,andyearofyourcorporationslastannualmeeting. Line4. Pleaseprovidenamesandaddresses,withnumberandstreet,cityortown,stateandzipcodeofallof?cersanddirectors.If onepersonisall,pleasere?ectthisfact.Ifthecorporationiscomposedofhusbandandwife,forexample,makesurethetitle ofeachisshownclearly. CLERK:MassachusettsLawrequiresthattheCLERKofthecorporationbearesidentofthestate,or,thataresidentagent beappointed.(Formsforthisareavailablebycallingourformsline,(617)727-9440.)Pleasebesuretoshowexpirationdates oftermsofof?ceofallof?cersanddirectors. Line5. M.G.L.-Chapter114,Section20requiresallcemeterycorporationswhichholdperpetualcarefundsto?leacopyofwrit- teninstrumentestablishingthetrustwiththestatesecretary. Completeandsignthestatementatthebottomofthepage,ensuringthattheof?cerwhomakesthestatementistheonewhosignsit,and makingcertainthatsuchof?cerislistedasanof?cer. This report must be led on or before November 1st with Filing Fee of $15.00. Please make Check payable to: Commonwealth of Massachusetts. InordertoassisttheCorporationsDivisioninprocessingyourAnnualReportasquicklyaspossible,pleaseaddressallreportsto: WilliamFrancisGalvin SecretaryoftheCommonwealth Att:AnnualReport-AR180 OneAshburtonPlace,Room1717 Boston,Massachusetts02108-1512 INCOMPLETEORINCORRECTREPORTSWILLBERETURNEDTOSENDERFORCOMPLETIONAND/ ORCORRECTION PLEASESENDORIGINALDOCUMENTONLY.Keepphotocopiesforyour?les. American LegalNet, Inc. www.USCourtForms.com
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