PHOENIX OFFICE TUCSON OFFICE 1300 West Washington Phoenix, Arizona 85007-2929 Phone: (602) 542-3026 Toll Free (AZ only): 1-800-345-5819 400 West Congress, Suite #221 Tucson, Arizona 85701-1347 Phone: (520) 628-6560 Toll Free (AZ only): 1-800-345-5819 www.azcc.gov www.azcc.gov 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 Rev: 09/2008 Page 1 of 2 Arizona Corporation Commission Corporations Division American LegalNet, Inc. www.FormsWorkflow.com Definitions: Pursuant to A.R.S §§ 10-1623 or 10-11623: 1. "Controlling" includes the total shares of stock issued to a husband and wife and their relatives to the first degree of consanguinity. 2. "Major stockholder" means a shareholder possessing or controlling twenty per cent of the issued and outstanding shares or twenty per cent of any proprietary, beneficial or membership interest in the corporation. SEND TO: ARIZONA CORPORATION COMMISSION PHOENIX CORPORATIONS DIVISION 1300 WEST WASHINGTON PHOENIX, AZ 85007-2929 OR TUCSON CORPORATIONS DIVISION 400 WEST CONGRESS, SUITE #221 TUCSON, AZ 85701-1347 Please Note: 1. Any person or corporation failing to comply with the requirements A.R.S §§ 10-1623 or 10-11623 is guilty of a class 1 misdemeanor *any person making a false statement or giving false information to the commission is guilty of a class 4 felony. *Pursuant to A.R.S §§ 10-1623 or 10-11623. 2. A corporation’s obligations pursuant to A.R.S. §§ 10-1623 and 10-11623 in no way absolves them from their obligation to file a corporate annual report as required by A.R.S. §§10-1622 or 10-11622. 3. All information required in this statement is public record. Do not submit documents containing social security numbers or other personal identifying information. Questions about this form can be directed to the Directors office at: 602-542-3521 or 602-542-3026. The Arizona Corporation Commission web site is: www.azcc.gov. American LegalNet, Inc. www.FormsWorkflow.com