ANNUAL REPORT 
 
ON DOMESTIC AND FOREIGN NON-PROFIT CORPORATIONS 
 
(DUE ON OR BEFORE JUNE 30TH OF EACH YEAR) 
 
PURSUANT TO SECTIONS 371 AND 373, CHAPTER 1, TITLE 13 OF THE VIRGIN ISLANDS CODE, REQUIRING 
THE FILING OF ANNUAL REPORTS BY DOMESTIC AND FOREIGN NON-PROFIT CORPORATIONS, THE 
FOLLOWING STATEMENT IS FILED WITH THE OFFICE OF THE LIEUTENANT GOVERNOR. 
 
 
NAME OF CORPORATION ………………………………………………………………………………………………….. 
 
TAX IDENTIFICATION NUMBER ………………………………………………………………………………………….. 
 
ADDRESS OF MAIN OFFICE ……………………………………………………………………………………………….. 
 
PRINCIPAL OFFICE IN THE VIRGIN ISLANDS …………………………………………………………………………... 
 
RESIDENT OR AUTHORIZED AGENT IN THE V.I. ………………………………………………………………………. 
 
COUNTRY OR STATE OF INCORPORATION …………………………………………………………………………….. 
 
FISCAL YEAR COVERED BY LAST REPORT FILED ¹ …………………………………………………………………... 
 
FISCAL YEAR COVERED BY THIS REPORT ² ……………………………………………………………………………. 
 
NAME AND ADDRESSES OF ALL DIRECTORS AND OFFICERS OF THE COMPANY AT THE CLOSE OF FISCAL 
YEAR AND EXPIRATION DATES OF TERMS OF OFFICE     *(Minimum of three different directors listed in 
addition to the officers of the corporation is required.  If space below is insufficient, please attach additional page(s) 
containing all director or officer information.  Format example: name, complete address, position, term expiration.) 
 
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REPORT DATED: ……………………………….. 
VERIFIED: …………………………………………………………... 
 
 
 
 
 
 
 
 
 
  (President)  or  (Vice President) 
 
 
 
 
 
 
 
 
 
                    …………………………………………………………… 
 
 
 
 
 
 
 
 
 
(Treasurer)  or   (Asst. Treasurer) 
 
 
 
1. 
If the last report filed does not cover the period immediately preceding the period covered by this report, a supplementary report on 
the same must be filed, bridging the gap, between the two reports. 
 
2. 
THIS REPORT IS NEITHER COMPLETE NOR ACCEPTABLE UNLESS ACCOMPANIED BY A GENERAL BALANCE SHEET 
AND PROFIT AND LOSS STATEMENT FOR THE LAST FISCAL YEAR AS REQUIRED BY THE VIRGIN ISLANDS CODE.  
FINANCIAL STATEMENTS SHOULD BE SIGNED BY AN INDEPENDENT PUBLIC ACCOUNTANT. 
REV. 12/2011