E-SR.AFR (v 20180619) Page 1 of 1
Financial Affairs Division
Arizona Department of Insurance
100 North 15
th
Avenue, Suite 102, Phoenix, Arizona 85007-2624
Phone: (602) 364-3245
Web: https://insurance.az.gov
SENIOR RESIDENTIAL ENTRANCE FEE CONTRACT PROVIDER
ANNUAL AUDITED FINANCIAL REPORT TRANSMITTAL FORM
GENERAL INSTRUCTIONS:
You are required to file an Audited Financial Report prepared by an Independent Certified Public Accountant
within 180 days after your fiscal year end each year.
YOU MUST COMPLETE AND ATTACH THIS FORM TO THE COVER OF YOUR AUDITED FINANCIAL
REPORT for filing identification and recording purposes.
REQUIRED INFORMATION:
Enter the information below the Provider whose Audited Financial Report is attached.
FISCAL YEAR END OF REPORT:
Enter the Provider’s Net Worth according to the
attached Report:
DO NOT ROUND TO THOUSANDS
Answer each question below.
1. Has this report been prepared in accordance with generally accepted accounting principles?
YES or NO . IF No, explain
2. Is the Auditor’s opinion qualified OR does the Report contain a statement that the Auditors have
substantial doubt about the Provider’s ability to continue as a going concern?
YES or NO . If YES, explain
3. Are subsequent events reported in the Notes to Financial Statements?
If YES, reference the Page Number of the Report:
ENTER THE COMPLETE NAME, TITLE, TELEPHONE NUMBER, AND EMAIL ADDRESS OF THE PERSON
TO BE CONTACTED FOR QUESTIONS CONCERNING THIS FILING:
Type or print name Title Telephone
Email address: Date completed:
