Form Ar:0014 - Statement Of Bankruptcy And/or Receivership - Arizona Corporation Commission

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1300 W. Washington St.
Phone: 602-542-3026
Phoenix, AZ 85007-2929
Toll free (within AZ only):
1-800-345-5819
ARIZONA CORPORATION COMMISSION
CORPORATIONS DIVISION
STATEMENT OF BANKRUPTCY AND/OR RECEIVERSHIP
Pursuant to A.R.S. §§10-1623 & 10-11623
_____________________________________________________________
(Exact corporate name in Arizona)
Pursuant to the provisions of A.R.S. §§10-1623 or 10-11623, the corporation named herein
delivers to the Arizona Corporation Commission the following information relevant to its:

Filing a Petition for Bankruptcy.
DATE (M/D/YR):
CASE NUMBER:________________________
COURT:
STATE: _______________
Appointment of a Receiver for the corporation.
DATE (M/D/YR):
CASE NUMBER:________________________
COURT:
STATE: _______________
RECEIVER NAME:_______________________________________________________
RECEIVER ADDRESS:_____________ ______________________________________
CITY, STATE, ZIP:_______________________________________________________
Exact name of the corporation in Arizona is:_________________________________________
Address: ____________________________________________________________________
City: _____________________________________ State: ______________ Zip: ___________
The corporation shall attach a statement listing the following information and deliver it to the commission:
1. All officers, directors, trustees and major stockholders of the corporation within one year of filing
the petition for bankruptcy or the appointment of a receiver. If a major stockholder is a
corporation, the statement shall list the current president, chairman of the board of directors and
major stockholders of such corporate stockholder.
2. Whether any such person has been an officer, director, trustee or major stockholder of any other
corporation within one year of the bankruptcy or receivership of the other corporation.
3. If the answer in paragraph 2 of this subsection is in the affirmative, for each such corporation the
following information:
(a) Name and address.
(b) States in which it:
(i) Was incorporated.
(ii) Transacted business.
(c) Dates of operation.
AR:0014
Arizona Corporation Commission
Rev: 10/2009
Page 1 of 2
Corporations Division

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