Filed for the year 20_____ Fee: $75.00 The Commonwealth of Massachusetts William Francis Galvin Secretary of the Commonwealth One Ashburton Place, Boston, Massachusetts 02108-1512 report of voluntary associations and trusts (General Laws, Chapter 182, Section 12) 1. Exact name of trust: 2. Street address of principal office in Massachusetts: 3. Street address elsewhere, if doing business outside Massachusetts: 4. Number of issued and outstanding transferable certificates of participation or shares: 5.The names and addresses of all the trustees are as follows: Name Address *I/We the trustee(s) of the above named trust, ___________________________________________________________________ , declare under penalties of perjury that I/we have examined this report and that to the best of my/our information and belief, the statements contained herein are true and correct and hereto sign my/our name(s) this _______day of_______________________________, 20_ _______ . **____________________________________________ ,Trustee _____________________________________________ ,Trustee *Delecte the inapplicable wards. **The trustee, or if more than one trustee, then at least two trustees, shall sign under the penalties of perjury. I have examined this Report of Voluntary Associations and Trusts and found it to conform with the requirements of Massachusetts General Laws, Chapter 182, Section 12 and the filing fee in the amount of $_ __________, having been paid, said report is deemed to have been filed with me this_ _______ day of_____________________ , 20_______ . _ William Francis Galvin Secretary of the Commonwealth 182rptva 6/13/01 American LegalNet, Inc. www.FormsWorkflow.com Every association or trust shall annually on or before June first, file with the Secretary of the Commonwealth a report signed under the penalties of perjury by its trustees, stating (a) the name of the association or trust; (b) the location (with street address) of its principal office in this Commonwealth and elsewhere if the trust or association does business outside the Commonwealth; (c) the number of its issued and outstanding transferable certificates of participation or shares; and (d) the names and addresses of its trustees. –General Laws, Chapter 182, Section 12 Instructions for completion of this form Note: Please type or print clearly as this document will be microfilmed. Incomplete or incorrect reports will be returned to sender for completion and/or correction. Please send original document only; keep a photocopy for your files. A. Item 1. Insert the exact name of the trust. Do not use any d/b/a names, trade names, or abbreviations. B. Item 2. Insert the full address of the trust’s principal office in Massachusetts, using number and street, city or town, state and zip code. C. Item 3. If the trust is doing business outside of Massachusetts, please insert it’s additional address. D. Item 4. Insert the number of issued and outstanding transferable certificates of participation or shares. E. Item 5. Insert the names and residential addresses of all the trustees. F. Complete the statement at the end of the form, insert date and sign where indicated. If more than one trustee exists, than at least two trustees must sign this report. G. Issue a check in the amount of $75.00 payable to the Commonwealth of Massachusetts. Attach check to the document and mail both to: William Francis Galvin, Secretary of the Commonwealth, Attention:Trust MT-1, One Ashburton Place, Room 1717, Boston, MA 02108-1512 American LegalNet, Inc. www.FormsWorkflow.com