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                                                                                      Office Use Only: Fiscal Year 

                      THE COMMONWEALTH OF MASSACHUSETTS 

                              OFFICE OF THE ATTORNEY GENERAL                                                    Print Form
                       NON-PROFIT ORGANIZATIONS/PUBLIC CHARITIES DIVISION  
                                              ONE ASHBURTON PLACE  
                                                                                       (617) 727-2200, ext. 2101 
                                          BOSTON, MASSACHUSETTS 02108
                                                                                       www.mass.gov/ago/charities

                                                       Form PC

Report for the Fiscal Period:                        to                               Check all items attached 
                                                                                      (if applicable)
Attorney General's Account #:
                                                                                       Schedule A-1
Federal ID #:                                                                          Schedule A-2
                                                                                       Schedule RO
When did the organization first engage in 
charitable work in Massachusetts?                                                      Probate Account
                                                                                       Copy of IRS Return
Has the organization applied for or been 
                                                       Yes              No             Audited Financial 
granted IRS tax exempt status?
                                                                                       Statements/Review
       If yes, date of application OR date of                                          Filing Fee
       determination letter:                                                           Amended Articles/ 
                                                                                       By-Laws
       IRS Exemption under 501(c):

       If exempt under 501(c), are contributions to 
       the organization tax deductible as charitable   Yes         No
       contributions? 

Organization Data
Name:

Mailing Address:

City:                                                                           State: Zip:

Phone Number:                                 Fax Number:

 Email:                                                   Website:

In the table below, please enter the appropriate codes from the corresponding tables found in the instructions. 
Enter up to 2 codes from Table 3 for your organization's main purpose(s)

                 Category                     Code                      Category       Code

       County (Table 1)                                Organization Purpose Code 1

       Type of Organization (Table 2)                  Organization Purpose Code 2

Please check box if final return prior to dissolution:
                                                                                      Office Use Only: Payment Received
Form PC                                                Page 1 of 14

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All questions must be completed in their entirety whether or not similar questions are answered in an attached federal form.
See instructions and definition section for guidance.

1. On what date was the organization created?

2. Where was the organization created?

3. What is the form of organization? (check one)

Corporation Testamentary Trust
Unincorporated Association Inter Vivos Trust
Other (please describe):

4. Was your organization related to any other organization(s) during the reporting year (see definition "Related
Organization")? If yes, please complete the Schedule RO on pages 13 and 14. Yes No

5. Enter your summary of financial data:
Financial Data Amounts
A. Contributions, gifts, grants, and similar amounts received
B. Gross support and revenue
C. Program services and similar amounts paid out
D. Fundraising expenses
E. Management and general expenses
F. Payments to affiliates
G. Total expenses
H. Net assets or fund balances at the end of the year

6. List the total compensation you provided to your five highest paid employees:
Hrs/ Salary and Other
Name/Title Benefit Plans
Week Other Income Compensation
1.
2.
3.
4.
5.

7. Was any compensation provided to any of the individuals listed in question 6 above which was not quantified in your
response to 6? If yes, please provide explanation (attach separate sheet). Yes No

Form PC Page 2 of 14 Rev. 02/2010

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8.    List the name, amount of compensation paid, and the nature of services rendered by each of the organization's 
       five highest paid consultants providing professional services (e.g. attorneys, architects, accountants, management 
       companies, investment advisors, professional solicitors, professional fundraising counsel).

                        Name/Title                            Amount of Compensation               Type(s) of Service
1.
2.
3.
4.
5.

9.    Bank(s) in which the organization's funds are deposited (include bank addresses and phone number):

                        Bank                                        Address                        Phone Number

10.   What is the organization's accounting method?           Cash          Accrual

                                                              Other specify): 

11.   If organization's mailing address os a P.O. Box, list the organization's full street address:

       Address:

       City:                                       State:                     Zip Code:

12.    Contact Person Name:

         Street Address:

         City:                                     State:                     Zip Code:

         Phone Number:

Form PC                                            Page 3 of 14                                         Rev. 02/2010

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13. During the fiscal year reported here, did your organization solicit contributions or have funds
Yes No
solicited on its behalf?

14. At any time during the fiscal year following the year reported here, will your organization, or
Yes No
others acting on its behalf, solicit contributions?
If you answered yes to Question 13 or 14, you must complete Schedule A-1 and/or Schedule A-2 unless you are
exempt from the solicitation certificate requirement.

15. If you are claiming and exemption from the solicitation certificate requirement, please indicate by checking the box to
the right to identify which exemption applies to your organization.

a religious organization
an organization which: (a) does not raise more than $5,000 during a calendar year Or does not
receive contributions from more than ten persons during a calendar year; AND (b) carries out all of its
activities, including fundraising, through unpaid volunteers. [The conditions at both (a) and (b) must
be met for your organization to qualify for this exemption.]

16. Attach a list of names, addresses (street and/or mailing), and telephone numbers of other offices/chapters/branches/
affiliates.

17. Attach a list of names, titles, and addresses (street and/or mailing) of officers, directors, trustees, and the principal
salaried executives of organization.

18. Attach a list of names, titles, and addresses (street and/or mailing) of any individual(s) authorized to sign checks,
and any individual(s) responsible for: custody of funds; distribution of funds; fundraising; and custody of financial
records.

19. Has this organization or any of its officers, directors, employees or fundraisers
Yes No
solicited funds in any other state?
If you attach list of states where solicitation was conducted, including registered agency, dates of registration,
registration numbers, any other names under which the organization was/is registered, and the dates and type
(mail, telephone, door to door, special events, etc.) of the solicitation conducted.

Form PC Page 4 of 14 Rev. 02/2010

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20. Has this organization or any of its officers, directors, or employees:
If yes, please attach an explanation.

(a) Been enjoined or otherwise prohibited by a government agency/court from
Yes No
operating or soliciting contributions?

(b) Ever been refused registration or had its registration or tax exemption denied,
Yes No
suspended, modified or revoked by a governmental agency?

(d) Entered into a voluntary agreement of compliance or consent judgment with,
Yes No
any government agency or in a case before a court or administrative agency?

21. Have any restrictions been removed during the year from donor-restricted funds?
If yes, please attach an explanation. Yes No

22. Have donor-restricted funds been loaned to unrestricted funds?
If yes, please attach an explanation. Yes No

23. This question involves "Termination of Employment or Changes of Control Compensatory Arrangements" with
certain "Related Parties" (see instructions and definition sections). Report only if payments made or promised to
any individual are in excess of four months salary or $100,000, whichever dollar amount is less.
(a) Did you make actual payments or otherwise transfer value under such an
arrangement to any individual described in Related Party definition,
sections (a) or (b), which payments are not reported in Question 6 or 7 above? Yes No

(b) Do you have an agreement with any individual described in Related Party
definition, sections (a) or (b), containing such an agreement? Yes No

If you answered yes for Question 23(a) or 23(b) above, please attach an explanation identifying the individual(s)
involved, stating the amount of any payments made or value transferred, and describing the terms of each agreement.

Form PC Page 5 of 14 Rev. 02/2010

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24. This question applies to related party transactions, which include transactions with officers, directors, trustees, certain
employees, relative, and organizations they own or control. Please consult the instructions and definition sections
for the definition of a "Related Party" and "Indebtedness" before answering. Note that transactions involving related
parties must be reported even when there is no accounting recognition (e.g. in-kind gifts, waiver or interest not
otherwise reported).

If the answer to any part of Question 24 is yes, attach a schedule stating the name and address of the related party,
the nature of the transaction, the value or the amounts involved in the transaction, and the procedure followed in
authorizing the transaction.

During the year:
Has your organization sold or transferred assets to or purchased assets from or
A. Yes No
exchanged assets with a related party?
B.Has your organization leased assets to or leased assets from a related party? Yes No
C.Has your organization been indebted to a related party? Yes No
D.Has your organization allowed a related party to be indebted to it? Yes No
E.Has your organization made or held an investment in a related party? Yes No
F.Has your organization furnished goods, services, or facilities to a related party? Yes No
Has your organization acquired goods, services, or facilities from a related party who
G. Yes No
received compensation or other value in return?
Has your organization paid or became obligated to pay wages, salary, or other
H. Yes No
compensation to a related party?
I.Has your organization transferred income or assets to or for use by a related party? Yes No
Was your organization a party to any transaction in which any of its officers, directors,
J.or trustees has a material financial interest, or did any officer, director or trustee receive Yes No
anything of value not reported as compensation?
Has your organization invested in any corporate stock of a company in which any
K. Yes No
officer, director, or trustee owns more than 10% of the outstanding shares?
Is any property of the organization held in the name of or commingled with the
L. Yes No
property of any other person or organization?
Did your organization make a grant award or contribution to any other organization
M. Yes No
in which any of of this organization's officers, directors or trustees has a relationship?

Form PC Page 6 of 14 Rev. 02/2010

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                        Signature Required
       Under penalty of perjury, I declare that the information furnished in this report, including all 
       attachment, is true and correct to the best of my knowledge.

       Signature:                                                          Date:

       Printed Name:

       Title:

       Name of Preparer:

       Address

       City             State                                      Zip Code

       Phone Number

Form PC                 Page 7 of 14                                            Rev. 02/2010

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                                          Schedule A-1 
       Solicitation Activities During Fiscal Year Covered By This Report

List any names which will be used by the organization in connection with the solicitation of funds, other than the official 
name which appears on page 1.

Types of solicitation activities in which you expect to engage (check all that apply):

Mass Mailing                                   Via the Internet
Door-to-door                                   Raffle, beano, bingo or gaming event
Entertainment event                            Sale of goods other than by telephone
Telemarketing without sale of goods or ads     Individual Mailings
Telemarketing with sale of goods               Corporate solicitations
Telemarketing with sale of ads                 Grant Proposals
       Other specify): 

Identify the method or methods you expect to use for the fundraising  (check all that apply):

Professional solicitor*                        Own employees
Professional fundraising counsel*              Volunteers
Commercial co-venturer*

* Provide applicable names and addresses:

Professional Solicitor Name:
Address
City                                      State                        Zip Code

Professional Fundraising Counsel Name:
Address
City                                      State                        Zip Code

Commercial Co-Venturer Name:
Address
City                                      State                        Zip Code

Form PC - Schedule A-1                    Page 8 of 14                                       Rev. 02/2010

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                              Schedule A-1 ctd. 
              Solicitation Activities During Fiscal Year Covered By This Report

Identify the individuals who will have final responsibility for the charity's custody of contributions:

Name and Title:Name and Title:
AddressAddress
City                          State             Zip Code

Name and Title:Name and Title:
AddressAddress
City                          State             Zip Code

Name and Title:Name and Title:
AddressAddress
City                          State             Zip Code

Identify the individuals who will have final responsibility for the charity's distribution of contributions:

Name and Title:Name and Title:
AddressAddress
City                          State             Zip Code

Name and Title:Name and Title:
Address
City                          State             Zip Code

Name and Title:
Address
City                          State             Zip Code

Form PC - Schedule A-1        Page 9 of 14                                                                  Rev. 02/2010

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                                          Schedule A-2 
Solicitation Activities Planned for Fiscal Year Which Follows the Reporting Year

List any names which will be used by the organization in connection with the solicitation of funds, other than the official 
name which appears on page 1.

Types of solicitation activities in which you expect to engage (check all that apply):

Mass Mailing                                   Via the Internet
Door-to-door                                   Raffle, beano, bingo or gaming event
Entertainment event                            Sale of goods other than by telephone
Telemarketing without sale of goods or ads     Individual Mailings
Telemarketing with sale of goods               Corporate solicitations
Telemarketing with sale of ads                 Grant Proposals
       Other specify): 

Identify the method or methods you expect to use for the fundraising  (check all that apply):

Professional solicitor*                        Own employees
Professional fundraising counsel*              Volunteers
Commercial co-venturer*

* Provide applicable names and addresses:

Professional Solicitor Name:
Address
City                                      State                        Zip Code

Professional Fundraising Counsel Name:
Address
City                                      State                        Zip Code

Commercial Co-Venturer Name:
Address
City                                      State                        Zip Code

Form PC - Schedule A-2                    Page 10 of 14                                      Rev. 02/2010

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                      Schedule A-2 ctd. 
Solicitation Activities Planned for Fiscal Year Which Follows the Reporting Year

Identify the individuals who will have final responsibility for the charity's custody of contributions:

Name and Title:
Address
City                  State             Zip Code

Name and Title:
Address
City                  State             Zip Code

Name and Title:
Address
City                  State             Zip Code

Identify the individuals who will have final responsibility for the charity's distribution of contributions:

Name and Title:
Address
City                  State             Zip Code

Name and Title:
Address
City                  State             Zip Code

Name and Title:
Address
City                  State             Zip Code

Form PC - Schedule A-2Page 11 of 14                                                                         Rev. 02/2010

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                                 Certification by Organization

Two different signatures required.  Signers must be organization president or other authorized officer or trustee.

Under penalty of perjury, we declare that the information furnished in this report, including all 
attachments, is true and correct to the best of our knowledge.

Signature:                                                    Date:

Printed Name:

Title:

Signature:                                                    Date:

Printed Name:

Title:

Form PC                          Page 12 of 14                                                    Rev. 02/2010

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                                          Schedule RO

1.   Please read the instructions and definition of "Related Organization" carefully before completing this section. 
      (If you have more than five Related Organizations, please attach a list.)

Name:                                     Primary purpose or activity:
FYE                  A. Donor restricted  B. 3rd party restricted C. Unrestricted funds D. Total net assets 
                     funds (-) liabilitiesfunds (-) liabilities   (-) liabilities       (A+B+C)

Name:                                     Primary purpose or activity:
FYE                  A. Donor restricted  B. 3rd party restricted C. Unrestricted funds D. Total net assets 
                     funds (-) liabilitiesfunds (-) liabilities   (-) liabilities       (A+B+C)

Name:                                     Primary purpose or activity:
FYE                  A. Donor restricted  B. 3rd party restricted C. Unrestricted funds D. Total net assets 
                     funds (-) liabilitiesfunds (-) liabilities   (-) liabilities       (A+B+C)

Name:                                     Primary purpose or activity:
FYE                  A. Donor restricted  B. 3rd party restricted C. Unrestricted funds D. Total net assets 
                     funds (-) liabilitiesfunds (-) liabilities   (-) liabilities       (A+B+C)

Name:                                     Primary purpose or activity:
FYE                  A. Donor restricted  B. 3rd party restricted C. Unrestricted funds D. Total net assets 
                     funds (-) liabilitiesfunds (-) liabilities   (-) liabilities       (A+B+C)

Form PC - Schedule RO                     Page 13 of 14                                        Rev. 02/2010

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                                              Schedule RO ctd.

2.   List the total compensation paid by your organization and/or any other related organization to your chief 
      executive (e.g., executive director) and to the four other current or former directors, trustees, officers, or 
      employees within the system of related organizations identified at question 1, above, receiving the highest 
      aggregate compensation (see instructions). Use additional lines below to itemize by compensation source.

Name:                                                  Title:
Income Source:                 Salary and Other Income:Benefits Plan:           Other Compensation

Name:                                                  Title:
Income Source:                 Salary and Other Income:Benefits Plan:           Other Compensation

Name:                                                  Title:
Income Source:                 Salary and Other Income:Benefits Plan:           Other Compensation

Name:                                                  Title:
Income Source:                 Salary and Other Income:Benefits Plan:           Other Compensation

Name:                                                  Title:
Income Source:                 Salary and Other Income:Benefits Plan:           Other Compensation

3.   Is asset and/or compensation information for religious organizations 
      and/or certain non-charitable entities related to foundations excluded YesNo
      pursuant to instructions?

Form PC - Schedule RO                         Page 14 of 14                                                          Rev. 02/2010

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