Form E-Afr.ohe - Audited Financial Report - Affidavit - 2015
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3Financial Affairs Division
Arizona Department of Insurance
th
2910 North 44
Street, Suite 210, Phoenix, Arizona 85018-7269
Phone: (602) 364-3245
Web:
https://insurance.az.gov
AUDITED FINANCIAL REPORT
GUIDELINES FOR STANDARDIZED ORGANIZATIONAL HARDSHIP EXEMPTION
AND
SAMPLE AFFIDAVIT
GENERAL INSTRUCTIONS
You may apply to the Director for an exemption if filing an Audited Financial Report (AFR) will create a
financial or organizational hardship.
Guidelines for a Standardized Organizational Hardship Exemption are shown on Page 2. If you meet
all of these criteria, apply for an exemption by completing the application requirements below.
DO NOT file this application if you qualify for automatic exemption. Use the Automatic Exemption
Notification in Page 2 of Form E-AFR.GFE instead.
APPLICATION REQUIREMENTS
Your application for an Organizational Hardship Exemption must include:
1.
A letter, signed by an officer who is authorized to sign your Annual Statement, requesting an
Organizational Hardship Exemption; AND
2.
A properly completed and signed affidavit. Use the affidavit form on Page 3. It must be signed by
an officer who is authorized to sign your Annual Statement.
DUE DATE
We must receive your application before
March
31st. LATE APPLICATIONS ARE NOT CONSIDERED.
SEND YOUR APPLICATION TO:
Financial Affairs Division
Arizona Department of Insurance
2910 North 44th Street, Suite 210
Phoenix, Arizona 85018-7269
DOCUMENTATION REQUIRED
You must provide documentation to support the statements made in your affidavit if we request it.
APPROVAL PROCESS
Your application is deemed approved upon receipt by us if it is complete, properly signed and we do
not notify you that it is not approved.
We may withdraw or rescind approval of an exemption if you do not meet all requirements.
OTHER HARDSHIP EXEMPTION
If you do not qualify for the automatic or standardized organizational hardship exemptions, you may still
apply for an exemption by sending us a letter requesting an organizational or financial hardship
exemption and an affidavit signed by one of your officers avowing to the facts which create the hardship.
We will notify you in writing that your application is granted or denied.
E-AFR.OHE (3/25/2015)
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