C003.001 Arizona Corporation Commission – Corporations Division
Rev: 2010 Page 2 of 2
5. BANKRUPTCY QUESTION:
5.1
Has any person (a) who is currently an officer, director, trustee,
incorporator, or (b) 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
(not the one filing this
Certificate) on the bankruptcy or receivership
of the other
corporation
?
Yes No
5.2
If the answer to number 5.1 is
YES
, you
MUST
complete and attach a Certificate of
form C005.
IMPORTANT: If within 60 days of the delivery of this Certificate to the A.C.C. any person not included in this
Certificate becomes an officer, director, trustee or person controlling or holding over ten per cent of the issued and
outstanding shares or ten per cent of any other proprietary, beneficial or membership interest in the corporation, the
corporation must submit a SUPPLEMENTAL Certificate providing information about that person, signed by all incorporators or
by a duly elected and authorized officer.
SIGNATURE REQUIREMENTS:
Initial Certificate of Disclosure:
This Certificate must be signed by all incorporators. If more space is needed,
complete and attach an form C084.
Foreign corporations: This Certificate may be signed by a duly authorized officer or by the Chairman of
the Board of Directors.
Credit Unions and Loan Companies:
This Certificate must be signed by any 2 officers or directors.
Name
Address 1
Address 2
City
Country
State
SIGNATURE – see Instructions C003i:
By typing or entering my name and checking the box marked
"I accept” below, I acknowledge under penalty of perjury that
this document together with any attachments is submitted in
compliance with Arizona law.
I ACCEPT
Signature
Printed Name Date
REQUIRED – check only one:
Incorporator - I am an incorporator of the
corporation submitting this Certificate.
Officer - I am an officer of the corporation
submitting this Certificate
Chairman of the Board of Directors - I am the
Chairman of the Board of Directors of the corporation
submitting this Certificate.
Director – I am a Director of the credit union or loan
company submitting this Certificate.
Name
Address 1
Address 2
City
Country
State
SIGNATURE – see Instructions C003i:
By typing or entering my name and checking the box marked
"I accept” below, I acknowledge under penalty of perjury that
this document together with any attachments is submitted in
compliance with Arizona law.
I ACCEPT
Signature
Printed Name Date
REQUIRED – check only one:
Incorporator - I am an incorporator of the
corporation submitting this Certificate.
Officer - I am an officer of the corporation
submitting this Certificate
Chairman of the Board of Directors - I am the
Chairman of the Board of Directors of the corporation
submitting this Certificate.
Director – I am a Director of the credit union or loan
company submitting this Certificate.
Filing Fee: None
All fees are nonrefundable - see Instructions.
Mail: Arizona Corporation Commission - Corporate Filings Section
1300 W. Washington St., Phoenix, Arizona 85007
Fax: 602-542-4100
Please be advised that A.C.C. forms reflect only the minimum provisions required by statute. You should seek private legal counsel for those matters that may pertain
to the individual needs of your business.
All documents filed with the Arizona Corporation Commission are public record and are open for public inspection.
If you have questions after reading the Instructions, please call 602-542-3026 or (within Arizona only) 800-345-5819.
ZipZip
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Disclosure Bankruptcy Attachment
Incorporator Attachment
