DOUGLAS A. DUCEY
GOVERNOR
JUDY LOWE
COMMISSIONER
COM-201 rev 6-11-2018
Arizona Department of Real Estate (ADRE)
Enforcement & Compliance Division
www.azre.gov
100 North 15
th
Avenue, Suite 201, Phoenix, Arizona 85007
COMPLIANCE AFFIDAVIT
(Respondent
& Designated Broker Notarized-Support Group Confirmation) (COM-201)
Licensee Name ___________________________ License #_________________
Print Name of Respondent
Consent Order Number: ___________________________ Consent Order dated _____________________
i.e.
= year F-DI-000 Commissioner’s Signature Date
I,_____________________________, hereby affirm that since the entering of the above Consent Order:
______ I have complied with all of the terms and conditions set forth in the above Consent Order.
initials
______ I have not violated any provision of the Title 32, Chapter 20 of the Arizona Revised Statutes.
initials
______ I have not violated any provision of the Title 4, Chapter 28 of the Arizona Administrative Code (Commissioner’s Rules).
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______ I attest to participation, bimonthly (at a minimum) in support group/counseling attendance specific to
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alcohol and/or drug abuse rehabilitation on the following dates: _______ ; _______; _______; _______; _______; ______.
1st date 2nd date 3rd date 4th date 5th date 6th date
I declare under the penalty of perjury that the above statements are
true. (Attach proof of attendance) THIS FORM MUST BE MAINTAINED FOR 5 YEARS.
___________________________________ _____________________
Respondent’s Signature Date
State of
Arizona County of ___________________
The foregoing instrument was acknowledged before me, _________________, this ______ day of __________, ______,
by__________________________.
My commission expires: ___________________ _____________________________________________
DESIGNATED BROKER’S (DB) AFFIDAVIT
I,_______
__________________________, Designated Broker for the above named Respondent, have reviewed the above Affidavit,
Print Designated Broker Name
and attest to the fact that I, as the named Practice Monitor, continue to monitor the compliance issues of the above named
Respondent.
___________________________________ _________________________ ______________
Designated Broker’s Signature Designated Broker’s License Number Date
State of
Arizona County of _____________
The foreg
oing instrument was acknowledged before me, _________________, this ______ day of __________, ______,
by__________________________.
My commi
ssion expires: ___________________ _____________________________________________
NOTARY PUBLIC
For more information or questions visit www.azre.gov
