Arizona Corporation Certificate of Disclosure Form

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Arizona Certificate of Disclosure Form

This form must be attched to the Articles of Incorporation when creating a new corporation in Arizona. No filing fee when submitting this form to the Secretary of State’s office.

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C003..001 Arizona Corporation Commission – Corporations Division
Rev: 2010 Page 1 of 2
DO NOT WRITE ABOVE THIS LINE; RESERVED FOR ACC USE ONLY.
CERTIFICATE OF DISCLOSURE
1. ENTITY NAME – give the exact name of the corporation in Arizona:
2. A.C.C. FILE NUMBER (if already incorporated or registered in AZ):________________________
Find the A.C.C. file number on the upper corner of filed documents OR on our website at: http://www.azcc.gov/Divisions/Corporations
3. Check only one of the following to indicate the type of Certificate:
Initial (accompanies formation or registration documents)
Annual (credit unions and loan companies only)
Supplemental to COD filed __________________ (supplements a previously-filed
Certificate of Disclosure)
4. FELONY/JUDGMENT QUESTIONS:
Has any person (a) who is currently an officer, director, trustee, or incorporator, or (b) who
controls or holds over ten per cent of the issued and outstanding common shares or ten per
4.1 Convicted of a felony involving a transaction in securities,
consumer fraud or antitrust in any state or federal jurisdiction
within the seven year period immediately preceding the signing
Yes No
4.2 Convicted of a felony, the essential elements of which consisted
of fraud, misrepresentation, theft by false pretenses or restraint
of trade or monopoly in any state or federal jurisdiction within
the seven-year period immediately preceding the signing of this
certificate?
Yes No
4.3 Subject to an injunction, judgment, decree or permanent order
of any state or federal court entered within the seven-year
period immediately preceding the signing of this certificate,
involving any of the following:
a. The violation of fraud or registration provisions of the
securities laws of that jurisdiction;
b. The violation of the consumer fraud laws of that
jurisdiction;
c. The violation of the antitrust or restraint of trade laws of
Yes No
4.4 If any of the answers to numbers 4.1, 4.2, or 4.3 are YES, you MUST complete
and attach a form C004.
Read the Instructions C003i
cent of any other proprietary, beneficial or membership interest in the corporation been:
of this certificate?
that jurisdiction?
Certificate of Disclosure Felony/Judgment Attachment
________________________________________________________________ C003.001 Arizona Corporation Commission – Corporations Division
Rev: 2010 Page 2 of 2
5. BANKRUPTCY QUESTION:
5.1 Has any person (a) who is currently an officer, director, trustee,
incorporator, or (b) who controls or holds over twenty per cent of
the issued and outstanding common shares or twenty per cent of
any other proprietary, beneficial or membership interest in the
corporation, served in any such capacity or held a twenty per
cent interest in any other corporation (not the one filing this
Certificate) on the bankruptcy or receivership of the other
corporation?
Yes No
5.2 If the answer to number 5.1 is YES, you MUST complete and attach a Certificate of
form C005.
IMPORTANT: If within 60 days of the delivery of this Certificate to the A.C.C. any person not included in this
Certificate becomes an officer, director, trustee or person controlling or holding over ten per cent of the issued and
outstanding shares or ten per cent of any other proprietary, beneficial or membership interest in the corporation, the
corporation must submit a SUPPLEMENTAL Certificate providing information about that person, signed by all incorporators or
by a duly elected and authorized officer.
SIGNATURE REQUIREMENTS:
Initial Certificate of Disclosure: This Certificate must be signed by all incorporators. If more space is needed,
complete and attach an form C084.
Foreign corporations: This Certificate may be signed by a duly authorized officer or by the Chairman of
the Board of Directors.
Credit Unions and Loan Companies: This Certificate must be signed by any 2 officers or directors.
Name
Address 1
Address 2
City
Country
State
SIGNATURE –
I ACCEPT
Signature
Printed Name Date
REQUIRED – check only one:
Incorporator – I am an incorporator of the
corporation submitting this Certificate.
Officer – I am an officer of the corporation
submitting this Certificate
Chairman of the Board of Directors – I am the
Chairman of the Board of Directors of the corporation
submitting this Certificate.
Director – I am a Director of the credit union or loan
company submitting this Certificate.
Name
Address 1
Address 2
City
Country
State
SIGNATURE –
I ACCEPT
Signature
Printed Name Date
REQUIRED – check only one:
Incorporator – I am an incorporator of the
corporation submitting this Certificate.
Officer – I am an officer of the corporation
submitting this Certificate
Chairman of the Board of Directors – I am the
Chairman of the Board of Directors of the corporation
submitting this Certificate.
Director – I am a Director of the credit union or loan
company submitting this Certificate.
Filing Fee: None (regular processing)
Expedited processing – add $35.00 to filing fee.
All fees are nonrefundable – see Instructions.
Mail: Arizona Corporation Commission – Corporate Filings Section
1300 W. Washington St., Phoenix, Arizona 85007
Fax: 602-542-4100
Please be advised that A.C.C. forms reflect only the minimum provisions required by statute. You should seek private legal counsel for those matters that may pertain
to the individual needs of your business.
All documents filed with the Arizona Corporation Commission are public record and are open for public inspection.
If you have questions after reading the Instructions, please call 602-542-3026 or (within Arizona only) 800-345-5819.
Zip Zip
Disclosure Bankruptcy Attachment
Incorporator Attachment
see Instructions C003i: see Instructions C003i:
By checking the box marked “I accept” below, I acknowledge
under penalty of perjury that this document together with
any attachments is submitted in compliance with Arizona
law.
By checking the box marked “I accept” below, I acknowledge
under penalty of perjury that this document together with
any attachments is submitted in compliance with Arizona
law.