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Arizona Administrative Code (Last Updated: November 17, 2016)

Title 14. PUBLIC SERVICE CORPORATIONS; CORPORATIONS AND ASSOCIATIONS; SECURITIES REGULATION

Chapter 1. CORPORATION COMMISSION CORPORATIONS AND ASSOCIATIONS

Article 2. CORPORATE NAMES

Section R14-1-102. Annual reports and certificates of disclosure

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A. This rule prescribes, pursuant to A.R.S. § 10-142, the form of the Annual Report and Certificate of Disclosure required to be filed with the Commission under A.R.S. §§ 10-125 and 10-

128. This rule does not apply to non-profit corporations.

B. Annual report of domestic and foreign corporations

1. Each domestic corporation and each foreign corporation authorized to transact business in this state shall file with the Commission an annual report setting forth the infor- mation required by A.R.S. § 10-125.

2. The annual reports of domestic and foreign corporations required to be filed under this subsection shall contain the following information which shall be set forth on the fol- lowing form provided by the Commission:

Corporation Commission - Corporations and Associations

415 WEST CONGRESS AVENUE TUCSON, ARIZONA 85701

ANNUAL REPORT ARS 10-125 & CERTIFICATE OF DISCLOSURE ARS 10-128

FORM PURSUANT TO ADMINISTRATIVE RULE R14-1-102

DIRECTION: Please complete both sides of this Annual Report, and return to the ARIZONA CORPORATION COMMISSION AT

EITHER OF THE ABOVE ADDRESSES WITH YOUR FEE. REPORT MUST BE FILED ON OR BEFORE:

Corporation Name: Street Address:

P.O. Box (if any): City, State, Zip Code:

Principal Office of

Non-Arizona Corporation: Suite # (if any):

City, State, Zip Code:

Name of Arizona Statutory Agent: Street Address:

City, State, Zip Code:

FILE NO.

ANNUAL REPORT FOR YEAR ENDING

MO. DAY YR.

TYPE OF CORPORATION FEE

B. SPECIAL INSTRUCTIONS: If there has been a change in any of the preceding information, please indicate below the change required:

C. * CAPITALIZATION: Aggregate number of shares itemized as follows: * NOT REQUIRED FOR NON-PROFIT CORPORATIONS

NUMBER AUTHORIZED	CLASS	SERIES	PAR VALUE



NUMBER AUTHORIZED	CLASS	SERIES	PAR VALUE

D. BRIEF STATEMENT OF THE CHARACTER OF BUSINESS IN WHICH THE CORPORATION IS ACTUALLY ENGAGED IN ARIZONA.

1.

Corporation Commission - Corporations and Associations

(LIST MUST BE COMPLETE - USE ADDITIONAL SHEET IF NECESSARY)

E. OFFICERS: F. DIRECTORS

President Director

Name _ Name _ Street Address _ Street Address _

P.O. Box _ P.O. Box

City, State Zip Code Date of taking this office: MO. _ DAY YR.

City, State Zip Code Date of taking this office: MO. DAY YR.

Vice-President Director

Name _ Name _ Street Address _ Street Address _

P.O. Box _ P.O. Box

City, State Zip Code Date of taking this office: MO. _ DAY YR.

City, State Zip Code Date of taking this office: MO. DAY YR.

Secretary Director

Name _ Name _ Street Address _ Street Address _

P.O. Box _ P.O. Box

City, State Zip Code Date of taking this office: MO. _ DAY YR.

City, State Zip Code Date of taking this office: MO. DAY YR.

Treasurer Director

Name _ Name _ Street Address _ Street Address _

P.O. Box _ P.O. Box

City, State Zip Code Date of taking this office: MO. _ DAY YR.

(OVER)

City, State Zip Code Date of taking this office: MO. DAY YR.

Other Executive Officer (title) _ Director

Name _ Name _ Street Address _ Street Address _

P.O. Box _ P.O. Box

City, State Zip Code Date of taking this office: MO. _ DAY YR.

City, State Zip Code Date of taking this office: MO. DAY YR.

Other Executive Officer (title) _ Director

Name _ Name _ Street Address _ Street Address _

P.O. Box _ P.O. Box

City, State Zip Code Date of taking this office: MO. _ DAY YR.

City, State Zip Code Date of taking this office: MO. DAY YR.

Other Executive Officer (title) _ Director

Name _ Name _ Street Address _ Street Address _

P.O. Box _ P.O. Box

City, State Zip Code Date of taking this office: MO. _ DAY YR.

City, State Zip Code Date of taking this office: MO. DAY YR.

Other Executive Officer (title) _ Director

Name _ Name _ Street Address _ Street Address _

P.O. Box _ P.O. Box

City, State Zip Code Date of taking this office: MO. _ DAY YR.

2.

City, State Zip Code Date of taking this office: MO. DAY YR.

Corporation Commission - Corporations and Associations

G. STATEMENT OF FINANCIAL CONDITION BALANCE SHEET

YOU MAY SUBSTITUTE FOR THIS BALANCE SHEET AN EXACT COPY OF THE FINANCIAL REPORT TO SHAREHOLDERS AS PROVIDED IN A.R.S. § 10-127, A COPY OF SCHEDULE L, FILED WITH THE INTERNAL REVENUE SERVICE, OR A COPY OF SCHEDULE L, FORM 120 FILED WITH THE ARIZONA DEPARTMENT OF REVENUE FOR THE PURPOSES OF TAXATION OF INCOME PURSUANT TO TITLE 43, ARIZONA REVISED STATUTES.

ASSETS	AMOUNT	TOTAL
Cash ........................................................................................		--------------------
Trade notes and accounts receivable .................................		--------------------
(a) Less allowance for bad debts ......................................	--------------------	--------------------
Inventories ...........................................................................		--------------------
Gov’t obligations: (a) U.S. and instrumentalities .............	--------------------
(b) State, subdivisions thereof, etc. ...................................	--------------------	--------------------
Other current assets .............................................................		--------------------
Loans to shareholders ..........................................................		--------------------
Mortgage and Real Estate loans ..........................................		--------------------
Other investments .................................................................		--------------------
Buildings and other fixed depreciable asset ....................	--------------------	--------------------
(a) Less accumulated depreciation ....................................	--------------------	--------------------
Depletable assets ..................................................................	--------------------
(a) Less accumulated depreciation ...................................	--------------------	--------------------
Land (net of any amortization) ............................................		--------------------
Intangible assets (amortizable only) ..................................	--------------------
(a) Less accumulated amortization ....................................	--------------------	--------------------
Other assets ...........................................................................		--------------------
Total assets........................................		--------------------
		--------------------

LIABILITIES AND CAPITAL

Accounts payable		--------------------
Mtges., notes, bonds payable in less than 1 yr. ..............		--------------------
Other current liabilities..........................................................		--------------------
Loans from shareholders ....................................................		--------------------
Mtges., notes, bonds payable in 1 yr. or more ...................		--------------------
Other liabilities ......................................................................		--------------------
Total assets............		--------------------
Capital stock: (a) Preferred stock ......		--------------------
(b) Common stock.......		--------------------
Paid-in-or capital surplus ....................................................		--------------------
Retained earnings - Appropriated .......................................		--------------------
Retained earnings - Unappropriated .................................		--------------------
Less cost of treasury stock ................................................		--------------------
Total capital......		--------------------
Total liabilities and Capital....		--------------------
		--------------------
	3.

Corporation Commission - Corporations and Associations

H. SHAREHOLDERS: DIRECTIONS: Fill in names of shareholders of record holding more than 20% of any class of shares issued by the

corporation, including persons beneficially holding such shares through nominees. If additional space is needed, attach a separate sheet.

Shareholder

Name

Shareholder

Name

Shareholder

Name

Shareholder

Name

Shareholder

Name

Shareholder

Name

I. ALL CORPORATE TAX RETURNS REQUIRED BY TITLE 43 HAVE BEEN FILED WITH THE ARIZONA DEPARTMENT OF REVENUE.

Under penalties of law, I declare that I have examined this report, including any attachments, and to the best of my knowledge and belief it is true, correct and complete. (MUST BE SIGNED BY PRESIDENT, VICE PRESIDENT, SECRETARY, ASSISTANT SECRETARY OR TREASURER.)

BY: X BY: X

TITLE: TITLE:

(Date of Signing)

NOTE:

If you are unable to file this Annual Report on or before the date which appears on page 1 of this report, you may, but only on or before that date, file a written request to the Incorporating Division, Annual Report Section for an extension of time, not to exceed 60 days, in which to file this report. The request for an extension of time MUST be accompanied by the annual fee which also appears in part A on page 1 of this report. Only after filing that request and paying the annual fee can the Commission grant this request for extension.

3. Each domestic and foreign corporation required to file the annual report on the form prescribed in this subsection may substitute for Part G of the form an exact copy of the financial report to shareholders as provided in A.R.S. § 10-127, a copy of Schedule L filed with the Internal Rev- enue Service, or a copy of Schedule L, Form 120 filed with the Arizona Department of Revenue for the purposes of taxation of income pursuant to Title 43, Arizona Revised Statutes.

C. Certificate of disclosure

1. The initial certificate executed by all incorporators shall be delivered to the Commission simultaneously with the

Articles of Incorporation or trust, or application for authority to transact business as provided by law.

2. All existing domestic and foreign corporations shall exe- cute a certificate of disclosure executed by any two offic- ers or directors of such corporation as part of the annual report required by A.R.S. § 10-125 unless otherwise exempted from the provisions of A.R.S. § 10-125 in which case they shall file said certificate of disclosure in a time and manner as provided by law.

3. The certificate of disclosure required to be filed by this subsection shall contain the following information which shall be set forth on the following form provided by the Commission:

Corporation Commission - Corporations and Associations

J. CERTIFICATE OF DISCLOSURE

A.R.S. 10-128 CHECK BOX “A” OR “B” WHICHEVER IS APPROPRIATE

THE UNDERSIGNED CERTIFY THAT

A.

No person serving either by election or appointment as officers, directors, trustees, incorporators and persons controlling, or holding more than 10% of the issued and outstanding common shares or 10% of any other proprietary, beneficial or membership interest in the corporation:

1. Have 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. Have been convicted of a felony, the essential elements of which consisted of fraud, misrepresentation, theft by false pretenses, or restraining of trade or monopoly in any state or federal jurisdiction within the seven year period immediately preceding the execution of this certificate.

3. Have 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, where 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 laws of trade laws of that jurisdiction.

B.

The following persons serving either by election or appointment as officers, directors, trustees, incorporators and persons controlling, or holding more than 10% of the issued and outstanding common shares or 10% of any other proprietary, beneficial or membership interest in the corporation, have been or are subject to one or more of the statements listed in items 1 through 3 above:

I. NAME(S) II. THE FOLLOWING INFORMATION ON EACH PERSON

LISTED MUST ACCOMPANY THIS REPORT.

1. Full name and prior names used. 2.Full birth name.

3. Present home address.

4. Prior addresses (for immediately preceding 7 year period). 5.Date and location of birth.

6. Social security number.

7. The nature and description of each conviction or judicial action, the date and location, the court and public agency involved, and the file or cause number of the case.

DATED: EXACT CORPORATE NAME:

Under penalties of law, I declare that I have examined this certificate, including any attachments, and to the best of my knowledge and belief it is true, correct and complete. (MUST BE SIGNED BY ANY TWO EXECUTIVE OFFICERS OR DIRECTORS OF THE CORPORATION.)

BY: X _ BY: X

TITLE:

TITLE:

NOTE: Date of signing

Before returning to the Commission, please make sure that you have signed part I AND part J of this report, please make sure that you have checked the appropriate box in part J of this report, and that you have submitted your check or other remittance for the annual fee which is required by law to accom- pany this report. If you have any questions, please contact the Annual Report Section of the Incorporating Division of the Arizona Corporation Commis- sion.

4.

D. This rule shall be effective December 31, 1977.

Historical Note

Former General Order I-3 not in original publication, cor- rection (Supp. 75-1). Former Section R14-1-102 repealed, new Section R14-1-102 adopted effective December 31, 1977 (Supp. 77-6).

                    
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