Form Cf:0001 - Nonprofit Certificate Of Disclosure printable pdf download

NONPROFIT

CERTIFICATE OF DISCLOSURE

Pursuant to A.R.S. § 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

Yes _______ No _______

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

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

6. The nature and description of each conviction or judicial action,

2. Full birth name.

date and location, the court and public agency involved and file or

3. Present home address.

case number.

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

5. Date and location of birth.

C. Has any person serving as an officer, director, trustee or incorporator of the corporation, served in any such capacity in any other

corporation in any jurisdiction on the bankruptcy or receivership of the other corporation?

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.

4. Dates of corporate operation.

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

5. A description of the bankruptcy or receivership, including the

involved.

date, court or agency and the file or case number.

3. State(s) in which the corporation:

(a) Was incorporated.

(b) Has transacted business.

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.

DATE

DATE_________________

TITLE

TITLE ___________________________________________________

DATE

DATE________________

TITLE

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 (60) 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.

CF: 0001 - Non-Profit

Arizona Corporation Commission

Rev: 09/2008

Corporations Division

Form Cf:0001 - Nonprofit Certificate Of Disclosure

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