Limited Liability Affidavit State of Arizona

							                           Arizona State Board for Charter Schools
                              Arizona State Board of Education
                                 1700 W. Washington St., Room 164, Phoenix, AZ 85007
                                         (602) 364-3080 Fax (602) 364-3089
                                                  www.asbcs.az.gov

                         CHARTER HOLDER GOVERNANCE NOTIFICATION REQUEST

(Charter Holder Name)              (CTDS)

(Charter Holder Mailing Address)

(City, State)          (Zip)

(Charter Representative’s Name)

(Phone Number)              (Fax Number)

                 Failure to submit all required documentation will result in the Notification Request being
                returned without being processed. Faxed copies will not be accepted. Please send originals.

          Changes in members of the corporate entity, or members of managers of a Limited Liability Company or
          manager of the Charter Holder.
          Please check this box if the Charter Holder and school governing body are the same.

    Included are the following:
                   Board minutes approving the change (If the body is subject to Open Meeting Law, minutes must comply with
                    ARS §38-431.01)
                   Valid Fingerprint Clearance Card for new corporate entity members
                   Notarized Affidavit, Disclosure, and Consent for Background Check (available on the ASBCS
                    website)
                   Background Information Sheet (available on the ASBCS website)
                   Provide information regarding any payment, benefit or consideration received or to be received by
                    any party in the transition.
                   Email address of new member


    The Arizona State Board for Charter Schools and              (Charter Holder), herein agree to amend the terms of the
    charter contract as follows:

    FROM:

    TO:

    In witness whereof, Charter Holder has signed this contract amendment as of this        day of      , 20   , and
    the State Board for Charter Schools has signed this contract amendment as of this _____ day of ______, 20___, to
    take effect at such time as it is signed by both parties.

    ___________________________________________________________________________
    Charter Representative Signature

    ___________________________________________________________________________
    Representative Signature for the Arizona State Board for Charter Schools




12/08/09