Certificate of disclosure

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C003.001   

                     Arizona Corporation Commission – Corporations Division 

Rev: 2016

                             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 five-year period immediately preceding the signing of 

this certificate?  

 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 five-year period immediately preceding the signing of this  

certificate?

 Yes

 No

      4.3

                  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.

C003i 

Read the Instructions

cent of any other proprietary, beneficial or membership interest in the corporation been:

that jurisdiction?

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Certificate of Disclosure Felony/Judgment Attachment

Subject to an injunction, judgment, decree or permanent order 

of any state or federal court entered within the five-year period 

immediately preceding the signing of this certificate, involving 

any of the following:  

Print Form

Clear Form

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C003.001 

                     Arizona Corporation Commission – Corporations Division 

Rev: 2016

                             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 – see Instructions C003i:

By typing or entering my name and 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.

 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 – see Instructions C003i:

By typing or entering my name and 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.

 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 

All fees are nonrefundable - see Instructions.      

Mail:     Arizona Corporation Commission - Corporate Filings Section 

            1300 W. Washington St., Phoenix, Arizona  85007 

Fax:      [phone]

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

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Disclosure Bankruptcy Attachment

I

ncorporator Attachment