INSTRUCTIONS: ARIZONA AFFIDAVIT (Form 71-1003)
Every person who wishes to assist in the conduct of any game of bingo in the state of Arizona must submit a form 71-1003. This affidavit can be found on the website maintained by the Arizona Department of Revenue. When completing the form, either type out your answers or print them in black ink.
Arizona Affidavit 71-1003 Step 1: In the first box, enter the licensee's name.
Arizona Affidavit 71-1003 Step 2: In the second box, enter the license number.
Arizona Affidavit 71-1003 Step 3: In the third box, check the appropriate box to indicate whether you will be a manager, supervisor, proceed coordinator or assistant.
Arizona Affidavit 71-1003 Step 4: In the fourth box, enter the affiant's name.
Arizona Affidavit 71-1003 Step 5: In the fifth box, enter the affiant's Social Security number. Note that making this disclosure is optional.
Arizona Affidavit 71-1003 Step 6: In the sixth box, enter the affiant's address.
Arizona Affidavit 71-1003 Step 7: In the seventh box, enter the affiant's date of birth.
Arizona Affidavit 71-1003 Step 8: In the eighth box, enter the affiant's city, state and zip code.
Arizona Affidavit 71-1003 Step 9: In the ninth box, enter the affiant's home phone number.
Arizona Affidavit 71-1003 Step 10: In the tenth box, enter the affiant's work phone number.
Arizona Affidavit 71-1003 Step 11: The next section is only to be completed if the licensee is a qualified organization. Indicate with a check mark whether the affiant is a member. If yes, enter the date on which they entered the organization.
Arizona Affidavit 71-1003 Step 12: On the next line, indicate with a check mark whether the affiant is an officer. If so, give their title.
Arizona Affidavit 71-1003 Step 13: Indicate with a check mark whether you have an affidavit on file for any other licensee. If yes, enter the license numbers.
Arizona Affidavit 71-1003 Step 14: Where indicated, the affiant should enter their name.
Arizona Affidavit 71-1003 Step 15: On the next to last blank line, the affiant should enter their signature.
Arizona Affidavit 71-1003 Step 16: On the last blank line, the affiant should enter the date.
Arizona Affidavit 71-1003 Step 17: Submit the affidavit to the address given at the top of the page.
