Filing Fee: $125.00
                                                                                                                                       Late Fee: $25.00
D F                      The Commonwealth of Massachusetts
                                                           William Francis Galvin
                                                          Secretary of the Commonwealth
                         One Ashburton Place - Room 1717, 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 corporation’s registered office in the commonwealth (number, street, city or town, state, zip code):

(4)  Name of the registered agent at the registered office:
(5)  Street address of the corporation’s principal office (number, street, city or town, state, zip code):

(6)  Provide the names and addresses of the corporation’s board of directors and its president, treasurer, secretary, and if different, its chief executive 
 officer and chief financial officer.
                                             NAME                                      ADDRESS
 President:
 Treasurer:
 Secretary:
 Chief Executive Officer:
 Chief Financial Officer:
 Directors: 

(7)  Briefly describe the business of the corporation:

(8-9) Capital stock of each class and series:

 CLASS OF STOCK                    TOTAL AUTHORIZED BY ARTICLES OF                                        TOTAL ISSUED AND OUTSTANDING
                                     ORGANIZATION OR AMENDMENTS                                           Number of Shares
                                             Number of Shares

 COMMON

 PREFERRED

(10) Check if the stock of the corporation is publicly traded. 

(11)  Report is filed for fiscal year ending:  ________________________ / _________________________ /  _____________________________
                                                          (month)              (day)                                           (year)

Signed by:  __________________________________________________________________________________________________________

  Chairman of the board of directors                       President            Other officer                                   Court-appointed fiduciary
on this ______________________________ day of _____________________________________________, __________________________ .

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