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Nonprofit Certificate of Disclosure (Arizona)

This is Certificate of Disclosure for a nonprofit corporation in Arizona. The form provided here is simply a sample of what the actual Form AZ CF0001 looks like.

ARIZONA CORPORATION COMMISSION
CORPORATIONS DIVISION

Phoenix Address: 1300 West Washington
Phoenix, Arizona 85007-2929

Tucson Address: 400 West Congress
Tucson, Arizona 85701-1347


NONPROFIT
CERTIFICATE OF DISCLOSURE

A.R.S. Section 10-3202.D.

EXACT CORPORATE NAME _______________________________

A. Has any person serving either by election or appointment as officer, director, trustee, or incorporator in the corporation:

1. Been 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 execution of this Certificate?

2. Been 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 execution of this Certificate?

3. Been or are subject to an injunction, judgment, decree or permanent order of any state or federal court entered within the seven-year period immediately preceding the execution of this Certificate wherein such injunction, judgment, decree or permanent order:

(a) Involved the violation of fraud or registration provisions of the securities laws of that jurisdiction?; or

(b) Involved the violation of the consumer fraud laws of that jurisdiction?; or

(c) Involved the violation of the antitrust or restraint of trade laws of that jurisdiction?

Yes ____ No ____

B. IF YES, the following information MUST be attached:

1. Full name and prior name(s) used.

2. Full birth name.

3. Present home address.

4. Prior addresses (for immediate preceding 7-year period).

5. Date and location of birth.

6. Social Security number.

7. The nature and description of each conviction or judicial action, date and location, the court and public agency involved and file or cause number of case.

C. Has any person serving either by election or appointment as an officer, director, trustee or incorporator of the corporation, served in any such capacity or held such interest in any corporation which has been placed in bankruptcy or receivership or had its charter revoked, or administratively dissolved by any jurisdiction?

Yes ____ No ____

IF YOUR ANSWER TO THE ABOVE QUESTION IS "YES", YOU MUST ATTACH THE FOLLOWING INFORMATION FOR EACH CORPORATION:

1. Name and address of the corporation.

2. Full name, including alias and address of each person involved.

3. State(s) in which the corporation:

(a) Was incorporated.

(b) Has transacted business.

4. Dates of corporate operation.

5. A description of the bankruptcy, receivership or charter revocation, including the date, court or agency and the file or cause number of the case.

D. The fiscal year end adopted by the corporation is _____________.

Under penalties of law, the undersigned incorporators/officers declare that we have examined this Certificate, including any attachments, and to the best of our knowledge and belief it is true, correct and complete, and hereby declare as indicated above. THE SIGNATURE(S) MUST BE DATED WITHIN THIRTY (30) DAYS OF THE DELIVERY DATE.

BY _______________________________

DATE _______________________________

TITLE _______________________________


BY _______________________________

DATE _______________________________

TITLE _______________________________


BY _______________________________

DATE _______________________________

TITLE _______________________________

DOMESTIC CORPORATIONS: ALL INCORPORATORS MUST SIGN THE INITIAL CERTIFICATE OF DISCLOSURE. (If more than four Incorporators, please attach remaining signatures on a separate sheet of paper.)

If within sixty days, any person becomes an officer, director, or trustee and the person was not included in this disclosure, the corporation must file an AMENDED certificate signed by all incorporators, or if officers have been elected, by a duly authorized officer.

FOREIGN CORPORATIONS: MUST BE SIGNED BY AT LEAST ONE DULY AUTHORIZED OFFICER OF THE CORPORATION.

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