~~It V~e' - . 0, , - Jersey City

Name of Business:
STOCKHOLDER DISCLOSURE CERTIFICATION
~ I certify that the list below contains the names and home addresses of all stockholders holding
10% or more of the issued and outstanding stock of the undersigned.
OR
IJ I certify that no one stockholder own 10% or more of the issued and outstanding stock of the
undersigned.
Check the box that represents the type of business organization:
(J Partnership IJ Corporation
IJ Limited Partnership JE Limited Liability Corporation
(J Subchapter S Corporation
IJ Sole Proprietorship
IJ Limited Liability Partership
Sign and notarize the form below, and, if necessary, complete the stockholder list belowo
Stockholders:
Name: Robert T. Hale, Jr. Name: Judith Hale
Home Address:
8 Olmsted Drive
Hingham, MA 02043
Name:' Name:
Home Address:
440 River Road
Westport, MA 02790
Home Address: Home Address:
Name: Name:
Home Address: Home Address:
l'
Subsc~ and swQ! before me this JL day of l' ~ Ut, 2
fJ/f) d _ ./~ 0_ Q.
~ .~r -- TlMOTHV JOHN FRENCH
(Notary Public) Notarv Public
Y ommission expires: l"ff .
M C .. .' I fJ /'5 Mv Commlliion Expire. Deember 15 2011
/4 COMMONWEALTH OF MASACHUSETS
iw Q I'ui,d_ 'fi
(Print n~ & title of affant)