PDF document

- 1 -

Office Use Only: Fiscal Year

THE COMMONWEALTH OF MASSACHUSETTS

OFFICE OF THE ATTORNEY GENERAL
Print Form
NON-PROFIT ORGANIZATIONS /PUBLIC CHARITIES IVISIOND
ONE ASHBURTON LACEP
BOSTON, MASSACHUSETTS 02108 (617) 963-2101
(617) 727-4765 TTY
www.mass.gov/ago/charities

Final Form PC (Form PC-F)

Report for the Fiscal Period:
Check all items enclosed
(if applicable)
Attorney General's Account #:
Officer's Certificate of Board
Authorization of the dissolution
Organization Data and any transfer of assets
Name: Administrative Petition
Judicial Complaint Package
Mailing Address:
3-year financial report for an
City: State: Zip: organization not required to file
Form PCs
Phone Number:

Email:

1. Is the organization in compliance with its reporting to the Division? Yes No
If "no", attach an explanation.

2. Does the Organization have any remaining assets to distribute? Yes No

3. Does the Organization have any financial activity after the last fiscal year-end? Yes No

4. Does the Organization have any outstanding debt or liabilities? Yes No
If "yes", attach an explanation.

Impact on Creditors: Any action by the Non-Profit Organizations/Public Charities Division with
respect to or involving the dissolution of a public charity shall not, in and of itself, affect any rights
otherwise held by any creditor of the dissolved organization. With respect to surviving rights of
creditors, see also G.L. c. 156B, §102 as applicable under G.L. c. 180, §10C.

5. Did the organization distribute any assets in anticipation of dissolution that Yes No
were not in the ordinary course of business, including those to a related party?

If "yes", attach an explanation.

6. Were any restrictions removed from the donor-restricted funds? Yes No
If "yes", attach an explanation.

Form PC-F Page 1 of 4 Rev. 06/2021

- 2 -

Enlarge image

7. Did the Organization engage in any related party transactions? Yes No
If "yes", answer the following questions and provide the requested information.

During this fiscal period:
Has your organization sold or transferred assets to or purchased assets from or
A. Yes No
exchanged assets with a related party?
B. Has your organization leased assets to or leased assets from a related party? Yes No
C. Has your organization been indebted to a related party? Yes No
D. Has your organization allowed a related party to be indebted to it? Yes No
E. Has your organization made or held an investment in a related party? Yes No
F. Has your organization furnished goods, services, or facilities to a related party? Yes No

Has your organization acquired goods, services, or facilities from a related party
G. Yes No
who received compensation or other value in return?

Has your organization paid or became obligated to pay wages, salary, or other
H. Yes No
compensation to a related party?
I. Has your organization transferred income or assets to or for use by a related party? Yes No

Was your organization a party to any transaction in which any of its officers,
J. directors, or trustees has a material financial interest, or did any officer, director or Yes No
trustee receive anything of value not reported as compensation?

Has your organization invested in any corporate stock of a company in which any
K. Yes No
officer, director, or trustee owns more than 10% of the outstanding shares?

Is any property of the organization held in the name of or commingled with the
L. Yes No
property of any other person or organization?

Did your organization make a grant award or contribution to any other organization
M. Yes No
in which any of this organization's officers, directors or trustees has a relationship?

Has your organization made any other payments, including a payment of debt, to a
N. Yes No
related party that is not disclosed above?

For each “yes” in Question 7, please state on separate pages and indicate the corresponding letter with the
following information: the name and address of the related party; a description of the relationship to the
dissolving entity; the nature of the transaction; the value, amount, or description of the property involved;
and the board action authorizing the transaction. See example below:

7(H) Ms. Jane Smith, 123 Main Street, Anytown, MA 12345-6789
Executive Director and Officer, annual salary $65,000, board authorized on 01/30/10

Form PC-F Page 2 of 4 Rev. 06/2021

- 3 -

Enlarge image

8. Complete the following for this fiscal period:
Financial Data Amounts
A. Contributions, gifts, grants, and similar amounts received
B. Gross support and revenue
C. Program services and similar amounts paid out
D. Fundraising expenses
E. Management and general expenses
F. Payments to affiliates
G. Total expenses
H. Net assets or fund balances at the end of the year

9. Are any funds being reserved to pay for dissolution-related expenses? Yes No
If "yes", attach an itemization of expected costs.

10. If there are remaining assets, please list the type of asset, name and address of proposed recipient, and value.
Please use additional pages as needed.

Description of Type of Asset Recipient Name and Address Related Party Approximate Value

Yes

Total Amount For Transfer:

11. Do the proposed recipients of funds and/or other property have a similar mission or
purpose to the dissolving organization and/or agree to use the funds or property for such Yes No
mission or purpose?
If "no", attach an explanation.

Form PC-F Page 3 of 4 Rev. 06/2021

- 4 -

Enlarge image

                 Signature Required
Under penalty of perjury, I declare that the information furnished in this report, including all 
attachments, is true and correct to the best of my knowledge.

Signature:                                                           Date:

Printed Name:

Title:

Address

City             State                                       Zip Code

Phone Number      Email:

Name of Preparer:

Address

City             State                                       Zip Code

Phone Number      Email:

Form PC-F        Page 4 of 4                                              Rev. 06/2021

PDF file checksum: 2655371944

(Plugin #1/9.12/13.0)