State of Rhode Island and Providence Plantations A. Ralph Mollis, Secretary of State Corporations Division 148 W. River Street Providence, RI 02904-2615 401.222.3040 Office of the Secretary of State PROFIT CORPORATION ANNUAL REPORT FOR THE YEAR ________________ Filing Period: January 1 - March 1 • Filing Fee: $50.00* • THIS REPORT MUST BE TYPED OR PRINTED LEGIBLY IN BLACK INK. * In accordance with R.I.G.L. 7-1.2-1501(e), each corporation failing or refusing to file its annual report within thirty (30) days after the time prescribed by law (R.I.G.L. 7-1.2-1501(c&d)) is subject to a penalty fee of $25.00. 1. Corporate ID No. 2. Name of Corporation 3. Street Address Principal Business Office 4. Business Phone No. State City Zip 5. State of Incorporation 6. Brief Description of the Character of Business Conducted in Rhode Island 7. NAMES AND ADDRESSES OF THE OFFICERS: (“X” BOX FOR ATTACHMENT) FILL IN SPACES BEFORE USING ATTACHMENTS President Name Vice President Name Street Address Street Address City State Zip City State State Secretary Name Zip Treasurer Name Street Address Zip Street Address City State Zip City 8. NAMES AND ADDRESSES OF THE DIRECTORS: (“X” BOX FOR ATTACHMENT) Director Name Street Address FILL IN SPACES BEFORE USING ATTACHMENTS Director Name Street Address City State Zip City State State Director Name Zip Director Name Street Address Zip Street Address City State Zip 9. SHARES AUTHORIZED City 10. SHARES ISSUED (“X” BOX FOR ATTACHMENT) ISSUED SHARES — THIS SECTION MUST BE COMPLETED This information is currently of record in the Office of the Secretary of State. Changes require an additional filing. See Section 9 of instruction sheet. Number of Shares Class/Series Par Value ED UST BE COMPLET THIS SECTION M This report must be executed on behalf of the corporation by an authorized representative. If the corporation is in the hands of a receiver or trustee, this report must be executed on behalf of the corporation by the receiver or trustee. Under penalty of perjury, I declare and affirm that I have examined this report, including any accompanying schedules and statements, and that all statements contained herein are true and correct. File Date ________________________________________ Signature Date Check No. ________________________________________ By: ______________________________________________ FOR SECRETARY OF STATE USE ONLY Print or Type Name Title Form 630 Rev. 08/08 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR FILING A PROFIT CORPORATION ANNUAL REPORT – Form 630 To avoid possible delays, please read all instructions carefully before completing the report. ________________________________________________________________________________ All sections, including the signature and date, must be completed; otherwise, the report will be returned to you. To file this report online using Visa, MasterCard, or American Express, visit www.sec.state.ri.us/corps and simply click on the “File Annual Reports Online” link. FOR IMAGING PURPOSES, THE REPORT MUST BE TYPED OR PRINTED LEGIBLY IN BLACK INK. The report must be signed and dated. An authorized representative shall execute it on behalf of the corporation; or, if the corporation is in the hands of a receiver or trustee, the receiver or trustee shall execute it on behalf of the corporation. Annual Reports are to be filed annually between the first day of January and the first day of March, but in no event should they be submitted for filing more than sixty (60) days prior to the commencement of the filing period. Failure to file the report and filing fee may result in revocation of the Certificate of Incorporation or the Certificate of Authority. An annual report must be filed even though the corporation may not be actively engaged in business at the time the report is due. Should you wish to dissolve or withdraw the corporation, please contact this office for the proper procedure. In accordance with R.I.G.L. 7-1.2-1501(e), each corporation failing or refusing to file its annual report within thirty (30) days after the time prescribed by law (R.I.G.L. 7-1.2-1501(c&d)) is subject to a penalty fee of $25.00. In order to accurately complete this form, please log onto our corporate database at www.sec.state.ri.us/corps to view your entity summary screen or to obtain a copy of your last annual report filing. ________________________________________________________________________________________________ Section 1. List your Rhode Island entity identification number. Please include this number on your check and refer to it in any future correspondence or filings with the Corporations Division. Section 2. List the exact corporate name as it appears on the Articles of Incorporation or latest amendment. If the corporate name has changed, an amendment must be filed with this office. Articles of Amendment forms (Domestic Corporations) or Amended Certificate of Authority forms (Foreign Corporations) can be obtained online at www.sec.state.ri.us/corps “Corporate Forms” or by calling 401-222-3040. Section 3. Provide the address of the principal office of the corporation. Section 4. Provide the telephone number of the principal office of the corporation. Section 5. List the state or country of incorporation. If the information is incorrect on your entity summary screen, please contact this office. Section 6. Provide a brief statement of the character of business in which the corporation is actually engaged in this state. If the corporation is inactive, this section must still be completed. Section 7. List the names and respective addresses of the officers of the corporation on the form. Do not leave areas blank. If the answer is none, write “none.” If additional space is needed, attachments will be accepted only after the designated areas on the form are completed. Check the appropriate box on the front of the annual report if submitting an attachment. Attachments must include the identification number of the corporation. Section 8. List the names and respective addresses of the directors of the corporation on the form. Do not leave areas blank. If the answer is none, write “none.” If additional space is needed, attachments will be accepted only after the designated areas on the form are completed. Check the appropriate box on the front of the annual report if submitting an attachment. Attachments must include the identification number of the corporation. Section 9. The corporation's exact number of authorized shares is of record in this office and can be found on the entity summary screen. If there has been a change in the authorized shares of a domestic corporation, Articles of Amendment must be filed. If there has been a change in the authorized shares of a foreign corporation, contact our office at 401-222-3040 for filing instructions. Section 10. Provide the number of issued shares along with the class, series and par value on the form. Do not leave this area blank. If the answer is none, write “none.” American LegalNet, Inc. www.FormsWorkflow.com