Arizona Form 99 - Arizona Exempt Organization Annual Information Return - 2014 Page 3
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1
2
3Name (as shown on page 1)
EIN
Under penalties of perjury, I declare that I have examined this return, including the accompanying schedules and statements, and to
Declaration
the best of my knowledge and belief, it is a true, correct and complete return, made in good faith, for the taxable year stated pursuant
to the income tax laws of the State of Arizona.
Please
Sign
Here
OFFICER’S SIGNATURE
DATE
TITLE
Paid
PAID PREPARER’S SIGNATURE
DATE
PAID PREPARER’S PTIN
Preparer’s
Use
FIRM’S NAME (OR PAID PREPARER’S NAME, IF SELF-EMPLOYED)
FIRM’S
EIN OR
SSN
Only
FIRM’S STREET ADDRESS
FIRM’S TELEPHONE NUMBER
CITY
STATE
ZIP CODE
Mail to: Arizona Department of Revenue, PO Box 52153, Phoenix, AZ 85072-2153
Print
ADOR 10418 (14)
AZ Form 99 (2014)
Page 3 of 3
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