REGISTRATION #_____________
D
N
W
T
S
State of Arizona
O
OT
RITE IN
HIS
PACE
Charitable Organization
Amendment/Cancellation
Mail to: Arizona Secretary of State Ken Bennett
Attention: Business Services, Charities Division
400 West Congress, 2nd Floor Room 252, Tucson, AZ 85701
(602) 542-6187 (800) 458-5842 (within Arizona)
Website:
F
O
U
O
– R
. 07/26/12
OR
FFICE
SE
NLY
EV
C
O
A
/C
(
A.R.S. § 44-6552)
HARITABLE
RGANIZATION
MENDMENT
ANCELLATION
About this form
How to complete this form
This form may be used to amend or cancel a Charitable
This form must be written legibly or computer generated for
Organization filed with the office under A.R.S. § 44-6552. A
accuracy. This form has been designed to be filled out and
copy of this law is available at .
printed online at the website referenced above.
Read this statement carefully, and fill in all blank spaces. If an
Filing Fee: None
item is not applicable, write “N/A” in the space.
File by mail to the address above or,
Return in person at the following locations:
PHOENIX - State Capitol
TUCSON - Arizona State
Executive Tower
Complex Building
1700 W. Washington Street
400 W. Congress
First Floor, Room 103
Second Floor, Room 252
These locations are open Monday through Friday, 8 a.m. to 5 p.m. except state holidays.
Please Type or Print
Amendment
Cancellation
Check One:
Charitable Organization Contact Information
Name of Charitable Organization
Charitable Organization Business Address
Business Address (include street, box or suite number)
City
State
Zip Code
Business Phone Number (include area code)
Amendment ~ The amendment to the registration on file of the charitable organization is as follow:
Cancellation
Effective date (month/day/year):
Reason for Cancellation:
5. Signature of Officer
Printed Name of Officer
Printed Title of Officer
Signature of Officer
Date signed (month/day/year)
Office Form SOSBSCharity_amend-cancel.doc
C hari t abl e Or gani zati on Am endm ent /C anc ellati on
Page 1 of 1