R14-1-102. Annual reports and certificates of disclosure

A. This rule prescribes, pursuant to A.R.S. § 10-142, the form of the Annual Report and Certificate of Disclosure required to be filed with the Commission under A.R.S. §§ 10-125 and 10- 128. This rule does not apply to non-profit corporations. B. Annual report of domestic and foreign corporations 1. Each domestic corporation and each foreign corporation authorized to transact business in this state shall file with the Commission an annual report setting forth the information required by A.R.S. § 10-125. 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: ANNUAL REPORT FOR YEAR ENDING MO. DAY YR. B. SPECIAL INSTRUCTIONS: If there has been a change in any of the preceding information, please indicate below the change required: 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. E. OFFICERS: F. DIRECTORS President Director (LIST MUST BE COMPLETE - USE ADDITIONAL SHEET IF NECESSARY) 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. ______ (OVER) 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. ______ 2. G. STATEMENT OF FINANCIAL CONDITION 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 ................................. -------------------- (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 liabilities Total capital...... -------------------- and Capital.... -------------------- -------------------- 3. 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. 3. Each domestic and foreign corporation required to file the annual report on the form prescribed in this subsection may substitute for Part G of the form 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. C. Certificate of disclosure 1. The initial certificate executed by all incorporators shall be delivered to the Commission simultaneously with the Articles of Incorporation or trust, or application for authority to transact business as provided by law. 2. All existing domestic and foreign corporations shall execute a certificate of disclosure executed by any two officers or directors of such corporation as part of the annual report required by A.R.S. § 10-125 unless otherwise exempted from the provisions of A.R.S. § 10-125 in which case they shall file said certificate of disclosure in a time and manner as provided by law. 3. The certificate of disclosure required to be filed by this subsection shall contain the following information which shall be set forth on the following form provided by the Commission: J. CERTIFICATE OF DISCLOSURE A.R.S. 10-128 CHECK BOX “A” OR “B” WHICHEVER IS APPROPRIATE THE UNDERSIGNED CERTIFY THAT A. 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: 1. Have been convicted of a felony involving a transaction in securities, consumer fraud or antitrust in any state or federal jurisdiction within the seven year period immediately preceding the execution of this certificate. 2. Have been convicted of a felony, the essential elements of which consisted of fraud, misrepresentation, theft by false pretenses, or restraining of trade or monopoly in any state or federal jurisdiction within the seven year period immediately preceding the execution of this certificate. 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 (c) Involved the violation of the antitrust or restraint laws of trade laws of that jurisdiction. 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) II. THE FOLLOWING INFORMATION ON EACH PERSON LISTED MUST ACCOMPANY THIS REPORT. 1.Full name and prior names used. 2.Full birth name. 3.Present home address. 4.Prior addresses (for immediately preceding 7 year period). 5.Date and location of birth. 6.Social security number. 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. 4. D. This rule shall be effective December 31, 1977.