Filing Fee: $15.00
               The Commonwealth of Massachusetts
                                              William Francis Galvin                                                M.G.L. Ch.180
                                              Secretary of the Commonwealth                                         Corporation
                One Ashburton Place, Room 1717, Boston, Massachusetts 02108-1512                                    Annual Report
                                              Telephone: (617) 727-9640
                                              ANNUAL REPORT

IDENTIFICATION                                                                 Filing for November 1, 20  ______________
NO. ______________________ 

In compliance with the requirements of Section 26A of Chapter one hundred and eighty (180) of the General Laws:

1. NAME: ___________________________________________________________________________________________________

2. ADDRESS: ________________________________________________________________________________________________ 
                               (number)                     (street)
____________________________________________________________________________________________________________
                (city or town)                                         (state)                                 (zip)
3. DATE OF THE LAST ANNUAL MEETING: ____________________________________________________________________

4. If the corporation is a cemetery corporation, it must hold perpetual care funds in trust and attach a copy of the written agreement estab-
 lishing the trust.  (check appropriate box)  
  
        The cemetery corporation certifies that perpetual care funds are held in trust and a copy of the written agreement  
       establishing the trust is attached. 
 OR

        The cemetery corporation hereby certifies that it does not hold perpetual care funds in trust.

5. State the names and addresses of the president, treasurer, clerk, at least one director of the corporation, and the date on which the term of 
 office of each expires: (PLEASE TYPE OR PRINT).

 NAME OF OFFICE                NAME                                    ADDRESSES                                    EXPIRATION  
                                                            Number, Street, City or Town,                           OF TERM OF
                                                                     State and Zip Code                                     OFFICE
 President:

 Treasurer:

 Clerk:
 (or Secretary)

 Directors:
 (or Officers 
 having the 
 powers of 
 Directors)

I, the undersigned  ________________________________________ being the  ____________________________ of the above-named 
corporation, in compliance with General Laws, Chapter 180, hereby certify that the information above is true and correct as of the dates 
shown.

IN WITNESS WHEREOF AND UNDER PENALTIES OF PERJURY, I hereto sign my name on this __________________________
day of _______________________________________ , 20 ______ .

Signature:     ____________________________________________Title:  ________________________________________________
Contact Person: _________________________________________Contact Person Telephone #: ______________________________
                                                                                                                            180npcar 11/15/13

INSTRUCTIONS: PLEASE TYPE OR PRINT CLEARLY AS DOCUMENT WILL 
              BE MICROFILMED AND CLARITY IS IMPORTANT.

NOTE:  INSERT FEDERAL IDENTIFICATION NUMBER (EMPLOYER'S I.D.). IF YOU DO NOT HAVE ONE YOU MUST AP-
        PLY TO THE INTERNAL REVENUE SERVICE.

Line 1. Insert the EXACT name of the corporation as it appears on the Articles of Organization or subsequent
        amendments. Do not use any d/b/a names, trade names, or abbreviations.

Line 2. State physical corporate address with number and street, city or town, state and zip code.

Line 3. Insert the month, day, and year of your corporation’s last annual meeting.

Line 4. M.G.L. - Chapter 114, Section 5C requires all cemetery corporations, which hold perpetual care funds in trust, to file a copy 
        of written instrument establishing the trust with the state secretary.

Line 5. Please provide names and addresses, with number and street, city or town, state and zip code of all officers and directors. If 
        one person is all, please reflect this fact. If the corporation is composed of husband and wife, for example, make sure the title 
        of each is shown clearly.
        CLERK: Massachusetts Law requires that the CLERK of the corporation be a resident of the state, or, that a resident agent 
        be appointed. (Forms for this are available at www.sec.state.ma.us/cor.) Please be sure to show expiration dates of terms of 
        office of all officers and directors.

Complete and sign the statement at the bottom of the page, ensuring that the officer who makes the statement is the one who signs it, and 
making certain that such officer is listed as an officer.

              This report must be filed on or before November 1st with Filing Fee of $15.00.
              Please make Check payable to: Commonwealth of Massachusetts.

In order to assist the Corporations Division in processing your Annual Report as quickly as possible, please address all reports to:

                                                         William Francis Galvin
                                                         Secretary of the Commonwealth
                                                         Att: Annual Report - AR180
                                             One Ashburton Place, Room 1717
                                             Boston, Massachusetts 02108-1512

INCOMPLETE OR INCORRECT REPORTS WILL BE RETURNED TO SENDER FOR COMPLETION AND/
OR CORRECTION

PLEASE SEND ORIGINAL DOCUMENT ONLY. Keep photocopies for your files.