E-LIFECARE.AMEND (v 20201031)
LIFE CARE PROVIDER ANNUAL REPORT AMENDMENT
FOR THE FISCAL YEAR ENDING:
(Full and Exact Corporate Name)
(Doing Business As / Or Facility Name)
(Statutory Home Office Address: Street & Number, City, State, Zip Code and phone number)
(Administrative Office Address: Street & Number, P.O. Box, City, State, Zip Code – enter phone numbers below)
organized under the laws of
(Month, Day, Year)
as a Non-Profit Corporation Stock Company Partnership
hereby submits the attached information and Exhibits in accordance with ARS § 20-1807.
I hereby depose and certify that I have prepared or reviewed this Report and it is true, complete, and
correct to the best of my knowledge and belief.
Signature of Chief Executive Officer ONLY Chief Executive Officer’s Name and Title
Subscribed and sworn to before me, this
Notary Signature My Commission Expires
Stamp or Seal here
Preparer's Name and Title Preparer’s Phone Number and E-Mail Address
THERE IS NO FILING FEE REQUIRED FOR THIS ANNUAL REPORT AMENDMENT.
Send the document to financialfilings@difi.az.gov
.