DOUGLAS A. DUCEY
GOVERNOR
JUDY LOWE
COMMISSIONER
form COM-104 rev 6-11-2018
Arizona Department
of Real Estate (ADRE)
Enfor
cement & Compliance Division
www.azre.gov
100 North 15
th
Avenue, Suite 201, Phoenix, Arizona 85007
COMPLIANCE AFFIDAVIT
(Respondent’s Signature Notarized) (COM-104)
Licensee Name: ___________________________ License #____________________
Print Name of Respondent
Consent Order Number: ___________________________ Consent Order dated _____________________
i.e. =yearF-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).
Initials
I declare under the penalty of perjury that the above statements are true. I agree to maintain the original signed Affidavit
for 5 years
__________
____________________ _______________
Respondent’s Signature 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
