The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Room 1717, Boston, Massachusetts 02108-1512 Telephone: (617) 727-9640 Filing Fee: $15.00 M.G.L. Ch.180 Corporation Annual Report ANNUAL REPORT IDENTIFICATION NO. ______________________ Filing for November 1, 20 ______________ 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 establishing 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 Number, Street, City or Town, State and Zip Code EXPIRATION OF TERM OF 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: ________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 180npcar 11/15/13 Contact Person: _________________________________________Contact Person Telephone #: ______________________________ 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 APPLY 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. State physical corporate address with number and street, city or town, state and zip code. Insert the month, day, and year of your corporation's last annual meeting. 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. 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. Line 2. Line 3. Line 4. Line 5. 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. American LegalNet, Inc. www.FormsWorkFlow.com