Form Cf:0022 - Certificate Of Disclosure - 2012
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1CERTIFICATE OF DISCLOSURE
A.R.S. §10-202(D) (for-profits and financial institutions) or §10-3202(D) (nonprofits)
____________________________________________________
EXACT CORPORATE NAME
A. Has any person (i) who is currently an officer, director, trustee, incorporator, or (ii) (for-profits and financial institutions only) who controls or
holds over 10% of the issued and outstanding common shares or 10% of any other proprietary, beneficial or membership interest in the
corporation been:
1. 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. 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. 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, prior name(s) and aliases, if used.
6. The nature and description of each conviction or judicial action,
2. Full birth name.
including the date and location, the court and public agency
3. Present home address.
involved and file or cause number of case.
4. Prior addresses (for immediate preceding 7-year period).
5. Date and location of birth.
C. Has any person (i) who is currently an officer, director, trustee, incorporator, or (ii) (for-profits and financial institutions only) 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 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 other corporation.
4. Dates of corporate operation.
2. Full name (including aliases) and address of each
5. Case information for bankruptcy or receivership (date, case
person involved.
number, court).
3. State(s) in which the other corporation:
(a) was incorporated.
(b) has transacted business.
Under penalties of law, the undersigned incorporator(s)/officer(s)/director(s) declare(s) that I(we) have examined this Certificate, including any
attachments, and to the best of my(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
BY_________________________________________________________
PRINT NAME
PRINT NAME ____________________________________________
TITLE
DATE
TITLE
DATE ______________
ARIZONA CORPORATIONS: ALL INCORPORATORS MUST SIGN THE INITIAL CERTIFICATE OF DISCLOSURE. If within sixty days any
person becomes an officer, director, trustee or (for-profits or financial institutions) person controlling or holding over 10% of the issued and
outstanding shares or 10% of any other proprietary, beneficial, or membership interest in the corporation and the person was not included in
this disclosure, the corporation must file a SUPPLEMENTAL certificate signed by at least one duly authorized officer of the corporation.
FOREIGN CORPORATIONS: MUST BE SIGNED BY AT LEAST ONE DULY AUTHORIZED OFFICER OF THE CORPORATION.
CREDIT UNIONS: MUST BE SIGNED BY TWO (2) DULY AUTHORIZED OFFICERS OR DIRECTORS OF THE CORPORATION.
CF:0022 – Corporations
Arizona Corporation Commission
Rev.: 05/2012
Corporations Division
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