CHAPTER 4
FORMS
[Prior to 7/13/88, see Secretary of State[750], Ch 4]
721—4.1(17A) Forms and instructions. Forms and instructions are developed by the agency in accordance with statutory directives.
Copies of forms and instructions of a general nature may be seen at the Office of Secretary of State, Statehouse, Des Moines, Iowa 50319. Copies of forms and instructions relating to corporation matters, the uniform commercial code, elections and other services may be seen at the respective divisions which are located in the Lucas State Office Building, Des Moines, Iowa 50319.
The subrules which follow list and describe those forms and instructions which members of the public use when dealing with the agency and its various divisions. Each direction of every instruction shall be complied with and each question or portion of every form answered in the same manner as if the forms and instructions were embodied in these rules.
	4.1(1) Forms of general application.

Form Number	Description	
GLO-1	Public disclosure of gifts made to a “local official,” “local employee” or to the person’s immediate family	
GEN-1	Certification of various filings in the office of the Secretary of State, for example, incorporation of cities, legislative bills and other documents	
	4.1(2) Notary public forms.

Form Number	Description	
NO-1	Application for appointment of Notary Public	
NO-2	Notarial Bond Form	
NO-3	Application for reappointment of Notary Public	
NO-4	Certificate of Notarial Commission	
NO-5	Certificate of Prothonotary	
Copies of application and bond forms for notaries public are available to the public upon request to the Notary Clerk, Office of the Secretary of State, Lucas State Office Building, Des Moines, Iowa 50319. The telephone number is (515)281-5204.
721—4.2(17A) Corporation forms.
	4.2(1) Nonprofit corporation forms.

Form Number	Description	
NP-1	Certificate of Good Standing — showing that a corporation is in good standing and also used to reflect that certain filings have not been made.	
NP-2	Certification Certificates — certifies copies attached are true reproductions of documents on file.	
NP-3	Certificate for Perpetual Fee Paid — issued to signify a Chapter 491 Corporation including domestic Insurance Companies have paid their perpetual fees due.	
NP-4	Trademark/Service Mark Certificate — issued to the holder of a trade or service mark.	
NP-5	Trademark/Service Mark Assignment Certificate — shows the transfer of a trade or service mark from the existing holder to a new registrant.	
NP-6	Nonprofit Voluntary Election to Adopt Certificate — showing that a Chapter 504 corporation has adopted Chapter 504A.	
NP-7	Foreign Nonprofit Qualification Certificate — issued to foreign nonprofit corporations qualified to do business in Iowa.	
NP-8	Nonprofit Application for Authority — used by foreign nonprofit corporations to obtain authority to do business in Iowa.	
NP-9	Amended Application for Authority-504A — used by foreign nonprofit corporations already qualified to reflect changes of name or authorized purposes.	
NP-10	Application for Withdrawal-504A — used by a foreign nonprofit corporation to stop business in Iowa.	
NP-11	Voluntary Election to Adopt-504A — corporations under old laws of Chapter 504 to adopt new law 504A.	
NP-12	Nonprofit Articles of Dissolution — for domestic nonprofit corporations to terminate their existence.	
NP-13	Suggested Form for Nonprofit Articles of Incorporation — a guide for drafting articles.	
NP-14	Suggested Form for Nonprofit Restated Articles of Incorporation — for nonprofit corporations desiring to rewrite the articles of incorporation.	
NP-15	Suggested Form for Nonprofit Amendment — a guide for drafting same.	
NP-16	Rules and Regulations for Trademarks/Service Marks — a short excerpt from the Code to help filing of trade and service marks.	
NP-17	Trademark/Service Mark Applications — self explanatory.	
NP-18	Trademark Assignment Application — to assign a mark from original registrant to a new registrant.	
NP-19	Trade/Service Mark Renewal Application — used every 10 years to renew mark.	
NP-20	Foreign Cooperative Application for Authority — cooperative from another state desiring to do business in Iowa.	
NP-21	Reinstatement of A Cooperative — used by a cancelled corporation for failure to file Annual Report to reinstate its rights.	
NP-22	Reinstatement of Nonprofit — same as above.	
NP-23	Certificate to Issue Capital Stock — for use by Chapter 491 Corporation and Insurance Corporations advising of stock issued.	
NP-24	Resolution Naming Resident Agent — Appointing service agent to represent old 491 Corporation.	
NP-25	Copy Order Request Form — used to order certified copies and good standing certificates.	
NP-26	Reinstatement Application-504A — for use by a cancelled corporation.	
	4.2(2) Business corporations.

Form Number	Description	
BC-1	Certificate of Incorporation — issued to reflect the existence of new corporation. Also used when articles are reinstated and for certificate of dissolution.	
BC-2	Certificate of Amendment — used to reflect corporate amendment mergers and consolidations.	
BC-3	Certificate of Adoption to the Iowa Business Corporation Act — issued to show adoption of Chapter 496A by a corporation under the old Chapter 491.	
BC-4	Certificate of Cancellation — issued to show cancellation for statutory reasons.	
BC-5	Certificate of Authority — issued to foreign business corporations which have qualified in Iowa.	
BC-6	Certificate of Revocation — issued to delinquent foreign corporations in lieu of cancellation.	
BC-7	Certificate of Reservation of Name — shows that a name is reserved for an applicant.	
BC-8	Application for Reinstatement — form by which cancelled business corporation can file for reinstatement of its rights.	
BC-9	Application for Reservation of Name — form by which applicant can reserve a corporate name for future use.	
BC-10	Application to Elect Assumed Name — used for corporation to apply for use of a secondary or dba name.	
BC-11	Application to Renew Assumed Name — used to renew assumed name from year to year.	
BC-12	Statement of Change of Registered Agent and Office — used by a corporation to change its official service agent and/or service office.	
BC-13	Statement of Change of Registered Agent and Office by Agent (Multiple Corporations) — same form as above, to be used when a person who is agent for numerous corporations changes address.	
BC-14	Application for Reinstatement — used by corporation cancelled for failure to file Annual Report to reinstate its rights.	
BC-15	Application for Amended Certificate of Authority — basically for foreign corporations already qualified to reflect change of name and Iowa purposes.	
BC-16	Application for Certificate of Authority — used by foreign corporations to obtain authority to do business in Iowa.	
BC-17	Application for a Foreign Corporation to Elect an Assumed Name — same as above.	
BC-18	Application for Registration of a Corporate Name — form by which foreign corporation may register name on a yearly basis.	
BC-19	Application for Renewal of Registration of Name — to renew registration of name (foreign).	
BC-20	Application for Certificate of Withdrawal — used by foreign corporation to stop business in Iowa.	
BC-21	Application for a Qualifying Assumed Name — special form of Assumed Name for use by foreign corporation whose official name cannot be used in Iowa.	
BC-22	Application for Transfer or Reservation of Name — to transfer a title from one to another.	
BC-23	Voluntary Election to Adopt Iowa Business Corporation Act — permits Chapter 491 Corporation to adopt Iowa Business Corporation Act (Chapter 496A).	
BC-24	Corporation Filing and Recording Fees — shows all filing and recording fees in the Corporation Division.	
	4.2(3) Annual reports.

Form Number	Description	
AR-1	Chapter 496A Iowa Domestic Annual Report — required of domestic corporations under the Iowa Business Corporation Act. (Will include instructions sheet designated as AR-25 for reporting year 1981)	
AR-2	Chapter 496A Foreign Corporation Annual Report — same as above for foreign corporations. (Will include instruction sheet designated as AR-26 for reporting year 1981)	
AR-3	Chapter 504A Iowa Nonprofit Annual Report — required for all Domestic Nonprofit Corporations.	
AR-4	Chapter 504A Foreign Nonprofit Annual Report — required to be filed by all Foreign Nonprofit Corporations.	
AR-5	Chapter 496C Iowa Professional Annual Report — required to be filed by Domestic Professional Corporations.	
AR-6	Chapter 496C Foreign Professional Annual Report — required to be filed by Foreign Professional Corporations.	
AR-7	Chapter 491 Iowa Annual Report (old chapter) — required to be filed by profit corporations who still remain under old Chapter 491.	
AR-8	Chapter 499 Non Stock Cooperative Annual Report — required to be filed by Chapter 499 non stock corporations.	
AR-9	Chapter 499 Stock Cooperative Annual Report — required to be filed by Chapter 499 stock issuing corporations.	
AR-10	Chapter 497 Cooperative Annual Report — required to be filed by old Chapter 497 Cooperatives.	
AR-11	Chapter 498 Cooperative Annual Report — required to be filed by old Chapter 498 Cooperatives.	
AR-12	September 496A Foreign Notice of Revocation — self explanatory.	
AR-13	October 496A Domestic Notice of Cancellation — self explanatory.	
AR-14	Chapter 496A Domestic Annual Report Instruction Sheet — self explanatory (see AR-1).	
AR-15	Chapter 496A Foreign Annual Report Instruction Sheet — self explanatory (see AR-2).	
AR-16	Chapter 496C Domestic Professional Corporation Annual Report Instruction Sheet — self explanatory (will become a part of Form AR-5 for reporting year 1982).	
AR-17	Chapter 496C Foreign Professional Corporation Annual Report Instruction Sheet — self explanatory (will become a part of Form AR-6 for reporting year 1982).	
	4.2(4) Farm reporting.

Form Number	Description	
FR-1	Agricultural Report	
FR-2	Information on Agricultural Reports	
FR-3	Pork and Beef Processor Report	
FR-4	Registration of Nonresident Alien Land Ownership	
FR-5	Nonresident Alien Ownership Report	
FR-6	Annual Agricultural Landholding Report	
For information concerning availability of forms for farm reporting, contact the Corporations Division, Hoover State Office Building, Des Moines, Iowa 50319, (515)281-8366.
This rule is intended to implement Iowa Code sections 172C.5A, 172C.5B, 172C.8 and 172C.9.
721—4.3(17A) Election forms.
Section 1. Election Day and Canvass Forms

Form Number	Description	
1-A(Rev.-95)	Voter’s Declaration of Eligibility	
1-B	(Reserved)	
1-C	(Reserved)	
1-D(Rev.-90)	Notice to Voter of Rejection of Absentee or Special Ballot	
1-E	(Reserved)	
1-F(Rev.-90)	Oath for Officer or Clerk of Election	
1-G(Rev.-95)	Statement to Person Casting a Special Ballot	
1-H(Rev.-95)	Envelope for Special Ballot	
1-I(Rev.-95)	Affidavit of Voter Requesting Assistance	
1-J(Rev.-95)	Declaration of Intent to Serve as Election Observer (Public Measure Elections)	
1-K(Rev.-90)	Ballot Record and Receipt	
1-L(Rev.-95)	County Abstract of Votes	
1-M(93)	Accreditation Form—Pollwatchers for Political Parties (Challenging Committees)	
1-N(93)	Accreditation Form—Observers for Political Parties (To Witness the Counting of Ballots)	
1-O(95)	Letter of Appointment—Pollwatchers for Nonpartisan and Nonparty Candidates	
1-P(95)	Application for Additional Ballots	
1-Q(95)	Application for Additional Ballots—Auditor’s Record of Telephone Request	
1-R(95)	Ballot Photocopy Record	
1-S(97)	Identification Statement	
Section 2. Nomination Documents and Forms	
Form Number	Description	
2-A(Rev.-97)	Affidavit by Candidate—Primary Election	
2-B(Rev.-97)	Affidavit by Candidate—Nominations by Political Parties	
2-C(Rev.-97)	Affidavit by Candidate—Nominations by Nonparty Political Organizations	
2-D(Rev.-97)	Affidavit by Candidate—Nonpartisan Nominations	
2-E(Rev.-97)	Nomination Paper—For U.S. Senator, U.S. Representative & Statewide Offices	
2-F(Rev.-97)	Nomination Paper—For State Senator	
2-G(Rev.-97)	Nomination Paper—For State Representative	
2-H(Rev.-97)	Nomination Paper—For Nonpartisan Nominations and Nonparty Political Organizations	
2-I(Rev.-93)	Certificate of Nomination by Nonparty Political Organization—Chapter 44	
2-J(Rev.-97)	Nomination Petition for the Offices of Electors for President and Vice President of the United States	
2-K(Rev.-97)	Nomination Paper for County Office	
2-L(Rev.-95)	Nomination by Convention—Certificate of Nomination by Political Party—Chapter 43	
2-M(Rev.-97)	Affidavit by Candidate—School and City Elections	
2-N(Rev.-97)	Affidavit by Candidate—City Elections—Chapter 44	
2-O(Rev.-97)	Nomination Petition—Merged Area Schools	
2-P(Rev.-97)	Petition Requesting Election	
2-Q(93)	Judicial Declaration of Candidacy	
2-R(93)	Certificate of Candidates for Presidential Electors	
2-S(Rev.-97)	Nomination Petition—Governor and Lieutenant Governor—Chapter 45	
Section 3. Absentee Voting Forms	
Form Number	Description	
3-A(Rev.-97)	Application for Absentee Ballot	
3-B(Rev.-97)	Absent Voter’s Affidavit and Envelope	
3-C(Rev.-90)	Affidavit for Voter Who Did Not Receive Absent Voter’s Ballot	
3-D(Rev.-97)	Absentee Ballot Carrier Envelope	
3-E(93)	Statement of Voter—Lost Absentee Ballot	
3-F(93)	Log for Absentee Ballot Delivery Team	
3-G(Rev.-95)	Challenge of Absentee Voter	
3-H(Rev.-97)	Statement to Voter of Change or Declaration of Party Affiliation	
3-I(97)	Statement to Voter of Change or Declaration of Party Affiliation for
Voter in Nursing Home or Hospital	
Section 4. Armed Forces and Overseas Absentee Voting	
Form Number	Description	
4-A(Rev.-97)	Armed Forces or Overseas Ballot—Delivery Envelope	
4-B(Rev.-97)	Armed Forces or Overseas Ballot—Return Carrier Envelope	
4-C(Rev.-97)	Armed Forces or Overseas Ballot—Affidavit Envelope	
4-D(93)	Proxy Absentee Ballot Request	
Section 5. Administrative Forms	
Form Number	Description	
5-A	(Reserved)	
5-B(Rev.-97)	Certificate of Test—Central Count Tabulating Equipment	
5-C(Rev.-97)	Certificate of Test—Precinct Count Tabulating Equipment	
5-D(Rev.-95)	Election Document Retention Record	
5-E	Rescinded	
This rule is intended to implement Iowa Code sections 43.13, 43.14, 43.18, 43.42, 43.43, 43.61, 43.67, 43.88, 44.3, 45.1, 45.3, 46.20, 48A.4, 48A.32, 49.65, 49.66, 49.77, 49.79, 49.80, 49.81, 49.90, 49.91, 49.104(2), 49.104(3), 49.104(5), 49.104(6), 50.3, 50.4, 50.5, 50.9, 50.10, 50.12, 50.19, 50.24, 50.26, 50.28, 51.11, 52.23, 52.35, 52.38, 53.2, 53.13, 53.19, 53.21, 53.22, 53.23(4), 53.25, 53.26, 53.30, 53.31, 53.40, 53.46(2), 54.5, 56.2(5), 260C.15(2), 277.4, 278.2, 331.306, 362.4 and 376.4 and 11 CFR, Subpart C, Section 8.7(1995).
721—4.4(17A) Uniform Commercial Code forms. For information concerning UCC forms, see 721—subrule 30.1(9). The UCC Division is located in the Lucas State Office Building, 321 E. 12th Street, Des Moines, Iowa 50319, telephone (515)281-5274.
This rule is intended to implement Iowa Code section 17A.3(1)“b.”
721—4.5(17A) Verified lien statement forms.

Form Number	Description	
VLS-1	(8″ x 13″) A five part snap-off form with interleaved carbon paper used for filing agricultural liens under Iowa Code chapter 570A.	
VLS-2	(8″ x 5″) A five part snap-off form with interleaved carbon paper used for filing assignments and acknowledgments of satisfaction as they relate to a VLS-1.	
This rule is intended to implement Iowa Code chapters 17A, 491, 496A, 497, 498, 499, 504A, Article IX and 1984 Iowa Acts, chapter 1072.
721—4.6(9A,17A) Athlete agent.

Form Number	Description	
AA-1	Application for Certificate of Registration — used to apply for a certificate of registration to act as an athlete agent in the state of Iowa.	
AA-2	Renewal Application for Certificate of Registration — used to annually renew the certificate of registration.	
AA-3	Consent to Service — required of nonresident athlete agents to provide irrevocable consent to service of process.	
AA-4	Surety Bond Form — required to show proof of continuous bonding of $25,000.	
This rule is intended to implement Iowa Code chapter 9A.
[Filed emergency 6/25/80—published 7/23/80, effective 7/l/80]
[Filed 9/24/80, Notice 8/20/80—published 10/15/80, effective 11/19/80]
[Filed 11/30/83, Notice 10/12/83—published 12/21/83, effective 1/25/84]
[Filed emergency 7/3/84—published 8/184, effective 7/3/84]
[Filed emergency 8/3/84—published 8/29/84, effective 8/3/84]
[Filed 12/14/84, Notice 8/1/84—published 1/2/85, effective 2/6/85]
[Filed emergency 7/6/87—published 7/29/87, effective 7/6/87]
[Filed emergency 8/4/87—published 8/26/87, effective 8/4/87]
[Filed 9/4/87, Notice 7/29/87—published 9/23/87, effective 10/28/87]
[Filed 6/23/88, Notice 5/18/88—published 7/13/88, effective 8/17/88]
[Filed emergency 7/8/88—published 7/27/88, effective 7/8/88]
[Filed 5/12/89, Notice 2/22/89—published 5/31/89, effective 7/19/89]
[Filed emergency 6/9/89—published 6/28/89, effective 7/1/89]
[Filed 8/16/89, Notice 5/17/89—published 9/6/89, effective 10/11/89]
[Filed 7/5/90, Notice 5/30/90—published 7/25/90, effective 8/29/90]
[Filed emergency 6/21/91—published 7/10/91, effective 7/1/91]
[Filed emergency 7/10/91—published 8/7/91, effective 7/10/91]
[Filed 8/13/93, Notice 6/23/93—published 9/1/93, effective 10/6/93]
[Filed 8/25/95, Notice 7/19/95—published 9/13/95, effective 10/18/95]
[Filed 8/22/97, Notice 7/16/97—published 9/10/97, effective 10/15/97]
[Filed 10/29/99, Notice 9/8/99—published 11/17/99, effective 12/22/99]
[Filed emergency 6/8/01—published 6/27/01, effective 7/1/01]
[Filed 12/30/05, Notice 11/23/05—published 1/18/06, effective 2/22/06]