Arizona Corporation Commission – Corporations Division
Rev: 6/2020 Page 1 of 1
Please read Instructions
DO NOT WRITE ABOVE THIS LINE; RESERVED FOR ACC USE ONLY.
STATUTORY AGENT ACCEPTANCE
1. ENTITY NAME –
give the exact name in Arizona of the corporation or LLC that has appointed the
Statutory Agent (this must match exactly the name as listed on the document appointing the
statutory agent, e.g., Articles of Organization or Articles of Incorporation):
STATUTORY AGENT NAME –
give the exact name of the Statutory Agent appointed by the
By the signature appearing below, the individual or entity named in number 2 above
accepts the appointment as statutory agent for the entity named in number 1 above, and
acknowledges that the appointment is effective until the appointing entity replaces the statutory
agent or the statutory agent resigns, whichever occurs first.
Signature Printed Name Date
– check only one
Individual as statutory agent:
signing on behalf of myself as the individual
Entity as statutory agent:
I am signing on
behalf of the entity named as statutory agent,
and I am authorized to act for that entity.
Filing Fee: none (regular processing)
All fees are nonrefundable - see Instructions.
The person signing below declares and certifies under penalty of perjury that the information
contained within this document together with any attachments is true and correct, and is
submitted in compliance with Arizona law.
entity listed in number 1 above (this will be either an individual or an entity). NOTE - the name
must match exactly the statutory agent name as listed in the document that appoints the
statutory agent (e.g. Articles of Incorporation or Articles of Organization), including any middle
initial or suffix:
STATUTORY AGENT SIGNATURE:
(natural person) named as statutory agent.
Expedited services are available for an additional fee – see Instructions or Cover sheet for prices.
Mail: Arizona Corporation Commission - Examination Section
1300 W. Washington St., Phoenix, Arizona 85007
If you have questions after reading the Instructions, please call 602-542-3026 or (within Arizona only) 800-345-5819.
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.