Certificate Of Disclosure - Arizona Corporation Commission
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DO NOT WRITE ABOVE THIS LINE; RESERVED FOR ACC USE ONLY.
CERTIFICATE OF DISCLOSURE
Read the Instructions
C003i
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:
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
cent of any other proprietary, beneficial or membership interest in the corporation been:
4.1
Convicted of a felony involving a transaction in securities,
consumer fraud or antitrust in any state or federal jurisdiction
Yes
No
within the seven year period immediately preceding the signing
of this certificate?
4.2
Convicted of a felony, the essential elements of which consisted
of fraud, misrepresentation, theft by false pretenses or restraint
Yes
No
of trade or monopoly in any state or federal jurisdiction within
the seven-year period immediately preceding the signing of this
certificate?
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
Yes
No
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
that jurisdiction?
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.
Certificate of Disclosure Felony/Judgment Attachment
C003..001
Arizona Corporation Commission – Corporations Division
Rev: 2010
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