INSTRUCTIONS: ARIZONA AFFIDAVIT (Form 71-1003)

As part of the Arizona bingo license application, an affidavit must be filed by each person who wishes to assist in the conduct of any game of bingo. This form 71-1003 can be obtained from the website maintained by the Arizona Department of Revenue.

Arizona Affidavit 71-1003 Step 1: Enter the licensee's name in the first blank box.

Arizona Affidavit 71-1003 Step 2: Enter the license number in the second blank box.

Arizona Affidavit 71-1003 Step 3: In the third blank box, indicate with a check mark whether the licensee is a manager, supervisor, proceed coordinator or assistant.

Arizona Affidavit 71-1003 Step 4: In the fourth blank box, enter the affiant's name.

Arizona Affidavit 71-1003 Step 5: In the fifth blank box, enter the affiant's Social Security number.

Arizona Affidavit 71-1003 Step 6: In the sixth blank box, enter the affiant's street address.

Arizona Affidavit 71-1003 Step 7: In the seventh blank box, enter the affiant's date of birth.

Arizona Affidavit 71-1003 Step 8: In the eighth blank box, enter the affiant's city, state and zip code.

Arizona Affidavit 71-1003 Step 9: In the ninth blank box, enter the affiant's home phone number, including the area code.

Arizona Affidavit 71-1003 Step 10: In the tenth blank box, enter the affiant's work phone number, including the area code.

Arizona Affidavit 71-1003 Step 11: The next five blank boxes are for qualified organizations only. In the first blank box, indicate with a check mark whether or not you are a member.

Arizona Affidavit 71-1003 Step 12: In the second blank box, enter the date you joined the organization.

Arizona Affidavit 71-1003 Step 13: In the third blank box, indicate with a check mark whether or not you are officers.

Arizona Affidavit 71-1003 Step 14: In the fourth blank box, if applicable, enter your officer title.

Arizona Affidavit 71-1003 Step 15: In the fifth blank box, indicate with a check mark whether you have an affidavit on file for any other licensee. If yes, list the license numbers.

Arizona Affidavit 71-1003 Step 16: On the first blank line, enter the affiant's name.

Arizona Affidavit 71-1003 Step 17: On the second blank line, the affiant should enter their signature.

Arizona Affidavit 71-1003 Step 18: On the last blank line, enter the date.