Ariz. Admin. Code § R14-1-102
B. Annual report of domestic and foreign corporations
2. The annual reports of domestic and foreign corporations required to be filed under this subsection shall contain the following information which shall be set forth on the following form provided by the Commission:
ARIZONA CORPORATION COMMISSION
2222 WEST ENCANTO BLVD. SUITE 210-D
PHOENIX, ARIZONA 85009
415 WEST CONGRESS AVENUE TUCSON, ARIZONA 85701
ANNUAL REPORT ARS 10-125 & CERTIFICATE OF DISCLOSURE ARS 10-128
FORM PURSUANT TO ADMINISTRATIVE RULE R14-1-102
DIRECTION: Please complete both sides of this Annual Report, and return to the ARIZONA CORPORATION COMMISSION AT
EITHER OF THE ABOVE ADDRESSES WITH YOUR FEE. REPORT MUST BE FILED ON OR BEFORE:
A. CORPORATION INFORMATION:
Corporation Name:
Street Address:
P.O. Box (if any):
City, State, Zip Code:
FILE NO.
TYPE OF CORPORATION
FEE
Principal Office of
Non-Arizona Corporation:
Suite # (if any):
City, State, Zip Code:
Name of Arizona Statutory Agent:
Street Address:
City, State, Zip Code:
C. * CAPITALIZATION: Aggregate number of shares itemized as follows: * NOT REQUIRED FOR NON-PROFIT CORPORATIONS
NUMBER AUTHORIZED CLASS SERIES PAR VALUE
NUMBER AUTHORIZED CLASS SERIES PAR VALUE
D. BRIEF STATEMENT OF THE CHARACTER OF BUSINESS IN WHICH THE CORPORATION IS ACTUALLY ENGAGED IN ARIZONA.
1.
(LIST MUST BE COMPLETE - USE ADDITIONAL SHEET IF NECESSARY)
E. OFFICERS: F. DIRECTORS
President Director
Name _______________________________________________ Name _______________________________________________
Street Address _______________________________________ Street Address _______________________________________
P.O. Box ____________________________________________ P.O. Box ____________________________________________
City, State Zip Code ___________________________________ City, State Zip Code ___________________________________
Date of taking this office: MO. ______ DAY ______ YR. ______ Date of taking this office: MO. ______ DAY ______ YR. ______
Vice-President Director
Name _______________________________________________ Name _______________________________________________
Street Address _______________________________________ Street Address _______________________________________
P.O. Box ____________________________________________ P.O. Box ____________________________________________
City, State Zip Code ___________________________________ City, State Zip Code ___________________________________
Date of taking this office: MO. ______ DAY ______ YR. ______ Date of taking this office: MO. ______ DAY ______ YR. ______
Secretary Director
Name _______________________________________________ Name _______________________________________________
Street Address _______________________________________ Street Address _______________________________________
P.O. Box ____________________________________________ P.O. Box ____________________________________________
City, State Zip Code ___________________________________ City, State Zip Code ___________________________________
Date of taking this office: MO. ______ DAY ______ YR. ______ Date of taking this office: MO. ______ DAY ______ YR. ______
Treasurer Director
Name _______________________________________________ Name _______________________________________________
Street Address _______________________________________ Street Address _______________________________________
P.O. Box ____________________________________________ P.O. Box ____________________________________________
City, State Zip Code ___________________________________ City, State Zip Code ___________________________________
Date of taking this office: MO. ______ DAY ______ YR. ______ Date of taking this office: MO. ______ DAY ______ YR. ______
Other Executive Officer (title) _________________________ Director
Name _______________________________________________ Name _______________________________________________
Street Address _______________________________________ Street Address _______________________________________
P.O. Box ____________________________________________ P.O. Box ____________________________________________
City, State Zip Code ___________________________________ City, State Zip Code ___________________________________
Date of taking this office: MO. ______ DAY ______ YR. ______ Date of taking this office: MO. ______ DAY ______ YR. ______
Other Executive Officer (title) _________________________ Director
Name _______________________________________________ Name _______________________________________________
Street Address _______________________________________ Street Address _______________________________________
P.O. Box ____________________________________________ P.O. Box ____________________________________________
City, State Zip Code ___________________________________ City, State Zip Code ___________________________________
Date of taking this office: MO. ______ DAY ______ YR. ______ Date of taking this office: MO. ______ DAY ______ YR. ______
Other Executive Officer (title) _________________________ Director
Name _______________________________________________ Name _______________________________________________
Street Address _______________________________________ Street Address _______________________________________
P.O. Box ____________________________________________ P.O. Box ____________________________________________
City, State Zip Code ___________________________________ City, State Zip Code ___________________________________
Date of taking this office: MO. ______ DAY ______ YR. ______ Date of taking this office: MO. ______ DAY ______ YR. ______
Other Executive Officer (title) _________________________ Director
Name _______________________________________________ Name _______________________________________________
Street Address _______________________________________ Street Address _______________________________________
P.O. Box ____________________________________________ P.O. Box ____________________________________________
City, State Zip Code ___________________________________ City, State Zip Code ___________________________________
Date of taking this office: MO. ______ DAY ______ YR. ______ Date of taking this office: MO. ______ DAY ______ YR. ______
G. STATEMENT OF FINANCIAL CONDITION
(a) Less allowance for bad debts ...................................... -------------------- --------------------
Inventories ........................................................................... --------------------
Gov't obligations: (a) U.S. and instrumentalities ............. --------------------
(b) State, subdivisions thereof, etc. ................................... -------------------- --------------------
Other current assets ............................................................. --------------------
Loans to shareholders .......................................................... --------------------
Mortgage and Real Estate loans .......................................... --------------------
Other investments ................................................................. --------------------
Buildings and other fixed depreciable asset .................... -------------------- --------------------
(a) Less accumulated depreciation .................................... -------------------- --------------------
Depletable assets .................................................................. --------------------
(a) Less accumulated depreciation ................................... -------------------- --------------------
Land (net of any amortization) ............................................ --------------------
Intangible assets (amortizable only) .................................. --------------------
(a) Less accumulated amortization .................................... -------------------- --------------------
Other assets ........................................................................... --------------------
Total assets ........................................ --------------------
--------------------
LIABILITIES AND CAPITAL
Accounts payable --------------------
Mtges., notes, bonds payable in less than 1 yr. .............. --------------------
Other current liabilities .......................................................... --------------------
Loans from shareholders .................................................... --------------------
Mtges., notes, bonds payable in 1 yr. or more ................... --------------------
Other liabilities ...................................................................... --------------------
Total assets............ --------------------
Capital stock: (a) Preferred stock ...... --------------------
(b) Common stock....... --------------------
Paid-in-or capital surplus .................................................... --------------------
Retained earnings - Appropriated ....................................... --------------------
Retained earnings - Unappropriated ................................. --------------------
Less cost of treasury stock ................................................ --------------------
Total capital...... --------------------
Total liabilities
and Capital.... --------------------
--------------------
BALANCE SHEET
YOU MAY SUBSTITUTE FOR THIS BALANCE SHEET AN EXACT COPY OF THE FINANCIAL REPORT TO SHAREHOLDERS AS PROVIDED IN A.R.S. § 10-127, A COPY OF SCHEDULE L, FILED WITH THE INTERNAL REVENUE SERVICE, OR A COPY OF SCHEDULE L, FORM 120 FILED WITH THE ARIZONA DEPARTMENT OF REVENUE FOR THE PURPOSES OF TAXATION OF INCOME PURSUANT TO TITLE 43, ARIZONA REVISED STATUTES.
ASSETS AMOUNT TOTAL
Cash ........................................................................................ --------------------
Trade notes and accounts receivable ................................. --------------------
H. SHAREHOLDERS: DIRECTIONS: Fill in names of shareholders of record holding more than 20% of any class of shares issued by the
corporation, including persons beneficially holding such shares through nominees. If additional space
is needed, attach a separate sheet.
Shareholder
Name
Shareholder
Name
Shareholder
Name
Shareholder
Name
Shareholder
Name
Shareholder
Name
I. ALL CORPORATE TAX RETURNS REQUIRED BY TITLE 43 HAVE BEEN FILED WITH THE ARIZONA DEPARTMENT OF REVENUE.
Under penalties of law, I declare that I have examined this report, including any attachments, and to the best of my knowledge and belief it is true,
correct and complete. (MUST BE SIGNED BY PRESIDENT, VICE PRESIDENT, SECRETARY, ASSISTANT SECRETARY OR TREASURER.)
BY: X BY: X
TITLE: TITLE:
(Date of Signing)
NOTE:
If you are unable to file this Annual Report on or before the date which appears on page 1 of this report, you may, but only on or before that date, file a written request to the Incorporating Division, Annual Report Section for an extension of time, not to exceed 60 days, in which to file this report. The request for an extension of time MUST be accompanied by the annual fee which also appears in part A on page 1 of this report. Only after filing that request and paying the annual fee can the Commission grant this request for extension.
C. Certificate of disclosure
J. CERTIFICATE OF DISCLOSURE
A.R.S. 10-128 CHECK BOX “A” OR “B” WHICHEVER IS APPROPRIATE
THE UNDERSIGNED CERTIFY THAT
A.
3. Have been or are subject to an injunction, judgment, decree or permanent order of any state or federal court entered within the seven year period immediately preceding the execution of this certificate, where such injunction, judgment, decree or permanent order:
(a)Involved the violation of fraud or registration provisions of the securities laws of that jurisdiction; or
(b)Involved the violation of the consumer fraud laws of that jurisdiction; or
No person serving either by election or appointment as officers, directors, trustees, incorporators and persons controlling, or holding more than 10% of the issued and outstanding common shares or 10% of any other proprietary, beneficial or membership interest in the corporation:
B.
The following persons serving either by election or appointment as officers, directors, trustees, incorporators and persons controlling, or holding more than 10% of the issued and outstanding common shares or 10% of any other proprietary, beneficial or membership interest in the corporation, have been or are subject to one or more of the statements listed in items 1 through 3 above:
I. NAME(S)
7. The nature and description of each conviction or judicial
action, the date and location, the court and public agency
involved, and the file or cause number of the case.
DATED: EXACT CORPORATE NAME:
Under penalties of law, I declare that I have examined this certificate, including any attachments, and to the best of my knowledge and belief it is true, correct and complete. (MUST BE SIGNED BY ANY TWO EXECUTIVE OFFICERS OR DIRECTORS OF THE CORPORATION.)
BY: X _________________________________________________ BY: X _________________________________________________
TITLE: _________________________________________________ TITLE: _________________________________________________
NOTE: Date of signing __________________________________________
Before returning to the Commission, please make sure that you have signed part I AND part J of this report, please make sure that you have checked the appropriate box in part J of this report, and that you have submitted your check or other remittance for the annual fee which is required by law to accompany this report. If you have any questions, please contact the Annual Report Section of the Incorporating Division of the Arizona Corporation Commission.
II. THE FOLLOWING INFORMATION ON EACH PERSON
LISTED MUST ACCOMPANY THIS REPORT.
1.Full name and prior names used.
Former General Order I-3 not in original publication, correction (Supp. 75-1). Former Section R14-1-102 repealed, new Section R14-1-102 adopted effective December 31, 1977 (Supp. 77-6).