Fillable No Pay Complaint Form 2 2019 (Arizona)

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No Pay Complaint Form 2 2019 (Arizona)

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The No Pay Complaint Form 2 2019 (Arizona) form is 2 pages long and contains:

  • 0 signatures
  • 4 check-boxes
  • 40 other fields

Country of origin: US
File type: PDF

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For Current or Suspended Licensees
Non-Payment Complaint Form
Instructions & Checklist
RCC099 01/16
Instructions
• Complete the entire complaint form. Incomplete or unsigned forms may be returned to you, which will delay
the complaint process.
• Attach copies of documents and information as listed in the checklist below with your complaint form. Include
copies of permits, invoices, advertisements, business cards and receipts. Do not send originals
as they will
not be returned to you.
• Do not attach the following information or documentation with your complaint:
Photos (this includes photos stored on a disk or flash drive)
Sets of plans, specifications, drawings, sketches, etc.
Samples (such as flooring, brick, paint, roofing, landscape rock, etc.)
Checklist
1) Contract
a) For written contracts, provide a copy of the original construction contract signed (by both parties) including all
addenda and change orders. If the only written documents describing the contract are a proposal, bid, or
invoice, please follow the instructions in b) for “if no written contract.”
b) If no written contract, provide a written statement describing the agreement that includes the following
information:
i) The reason a written contract is not being provided (e.g. the contractor did not provide a written contract,
the contract is lost, the contract was destroyed);
ii) A description of any written documents used to describe the contract, e.g. bids, proposals, invoices,
receipts. (If you have copies of any of these documents, please provide them with the Complaint Form.);
iii) A description of the work to be performed under the contract (including any addenda or change orders);
iv) The names of the people who negotiated the contract;
v) The agreed upon payment schedule;
vi) An explanation of who was to receive payment; and
vii) The date the work was to be completed.
c) For complaints of non-payment between contractors, vendors, or material suppliers, provide a copy of:
i) The credit applications. Redact all SSN and/or EIN information.
ii) Invoices for services rendered and/or materials delivered.
2)
Proof of Debt(s); Acceptable forms of proof of debt are copies of:
a)
Invoices.
b)
Contracts.
c)
Promissory notes.
d)
Other negotiable instruments.
Non-Payment Complaint Form Departmental Use Only
Complaint Number:
Mail to:
Registrar of Contractors
P.O. Box 18243
Phoenix, AZ 85005-8243
Person Filing Complaint (Payee)
Business Name
Full Name (First Middle Last)
ROC License Number(s) (if any)
Street Address
City
State
Zip Code
Phone Number
I consent to receive communications electronically in connection with this case.
Yes
☐
No
☐
Name of Attorney (if any)
Attorney’s Street Address
City
State
Zip Code
Attorney’s Phone Number
Attorney’s Email Address
Licensee Information (Payer)
ROC License Number(s)
Street Address
City
State
Zip Code
Phone Number
Name of Person(s) Representing License
Complaint Information
Contract Date (if applicable)
Have you filed a civil complaint?
Yes
☐ (If yes, provide a copy of the civil judgment)
No
☐
List all specific invoices which have not been paid. Attach additional pages if necessary.
1.
2.
3.
4.
5.
Certification
I certify, upon information and belief, that the above-named licensee has failed to pay monies in excess of seven hundred fifty dollars when
due for materials or services rendered in connection with the licensee’s operations as a contractor. I further certify, upon information and
belief, that the above-named licensee has the capacity to pay, or has received sufficient monies as payment for the particular construction
work project or operation for which the services or materials were rendered or purchased. A.R.S. § 32-1154(A)(10).
Printed Name
Signature
Date
Declaration & Signature
I am the Complainant in this Complaint Form or Complainant’s duly authorized representative. I declare under penalty of perjury that
the information contained in this Form is true and correct to the best of my knowledge. I further certify that any documents submitted in
support of this complaint are true and correct copies of the originals and are accurate to the best of my knowledge. I will assist in the
investigation or in the prosecution of the contractor or other parties, and will, if necessary, attend hearings and testify to facts.
Printed Name
Signature
Date
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No Pay Complaint Form 2 2019 (Arizona)

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Completed 21 July 2020

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