Corporate Tax Commitment Form

A.R.S. § 43-1183 or A.R.S. § 20-224.06 or A.R.S. § 43-1184 or A.R.S. § 20-224.07
Corporate Name*
Type:

C-CORPORATIONS-CORPORATIONINSURANCE COMPANY
EIN*
Contact Name*
Title
Street Address*
City/State/Zip*
Phone *
NAIC (if applicaple)
Donation Amount*
Donation Amount

Please apply this contribution towards Disabled, Displaced, and/or Foster Care students in need.Please apply this contribution towards Low Income students in need.Please apply this contribution towards where the greatest need is.
The Contributor Understands that:

1. Azura will complete the appropriate documentation and submit this application to the Arizona Department of Revenue (AZDORWithin 20 days, the AZDOR will respond to Azura as to whether the request is within this fiscal year’s cap.

2. When Azura receives approval from the AZDOR, we will notify you. You will have 20 calendar days to make your payment to Azura.

3.Azura will send you a receipt with your approval number that is submitted with an AZDOR form with your tax return as proof of payment.
Signature*

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Name*
Title*
Date*

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Please let us know if you would like us to share with our scholarship recipients your contribution information:

YES - you may release our identity and amount.YES - you may release our identity.NO - please keep our identity and amount confidential.
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