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Sec. 157.062(6) Wis. Stats.

State of Wisconsin Department of Financial Institutions Division of Corporate and Consumer Services

CEMETERY ASSOCIATION AFFIDAVIT AND CERTIFICATE OF REORGANIZATION

The undersigned Chairperson and Secretary of , a Wisconsin Cemetery Association (the "Association") having its principal place of business in the following: 1. A. The Association was dissolved by failure to hold an annual election for three successive years. County, Wisconsin, do hereby certify

OR B. The Association was never properly organized as a cemetery association.

2. The Association owns cemetery grounds in which human remains are buried and wishes to continue conducting business as a cemetery association.

3.

Upon filing of this Affidavit, the name of the Association will be:

____________________________________________________________________________

4.

The annual meeting of the Association shall be held each year on: ______________________

5.

The principal office address of the Association is: (Provide complete mailing address.)
PO Box State Zip

Business Address: Street City

NO FILING FEE
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Sec. 157.062(6) Wis. Stats.

6. The Association has five (5) or more members who are all residents of county, Wisconsin and whose names, home addresses and business addresses are as follows: (Attached schedule if necessary.) Member 1
Name: First Business Address: Street Home Address: Street M.I. Last City City State State Zip Zip

Member 2
Name: First Business Address: Street Home Address: Street M.I. Last City City State State Zip Zip

Member 3
Name: First Business Address: Street Home Address: Street M.I. Last City City State State Zip Zip

Member 4
Name: First Business Address: Street Home Address: Street M.I. Last City City State State Zip Zip

Member 5
Name: First Business Address: Street Home Address: Street M.I. Last City City State State Zip Zip

7. A meeting was held on (date) , pursuant to a notice published in accordance with Chapter 985, Wis. Stats., for the purpose of reorganizing the Association and electing trustees. 8. Attached is a complete and correct record of the proceedings from the meeting, signed by the Secretary of the Association.

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Sec. 157.062(6) Wis. Stats.

9. The following individuals are elected trustees of the Association, identified by name, business address and home address, class and expiration of term of office: CLASS I
Name: First Business Address: Street Home Address: Street

(Terms expire
M.I.

.)
Last City City State State Zip Zip

Name: First Business Address: Street Home Address: Street

M.I.

Last City City State State Zip Zip

Name: First Business Address: Street Home Address: Street

M.I.

Last City City State State Zip Zip

CLASS II
Name: First

(Terms expire
M.I.

.)
Last City City State State Zip Zip

Business Address: Street Home Address: Street

Name: First Business Address: Street Home Address: Street

M.I.

Last City City State State Zip Zip

Name: First Business Address: Street Home Address: Street

M.I.

Last City City State State Zip Zip

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Sec. 157.062(6) Wis. Stats.

Trustees ­ continued CLASS III
Name: First Business Address: Street Home Address: Street

(Terms expire
M.I.

.)
Last City City State State Zip Zip

Name: First Business Address: Street Home Address: Street

M.I.

Last City City State State Zip Zip

Name: First Business Address: Street Home Address: Street

M.I.

Last City City State State Zip Zip

9.A. OPTIONAL, Identified among the above trustees are the President, Secretary and Treasurer of the Association. (Strike the word "OPTIONAL" if the names of officers are included.)

10. The undersigned are the duly elected Chairperson and Secretary elected at the reorganizational meeting of the Association. IN WITNESS WHEREOF, the undersigned officers have executed this Certificate, in duplicate and in their respective capacities on behalf of the Association on this ___________ day of

________________________, 20_______. _______________________________
(Chairperson Printed Name)

_____________________________
(Secretary Printed Name)

_______________________________
(Chairperson Signature)

______________________________
(Secretary Signature)

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Sec. 157.062(6) Wis. Stats.

NOTARY SECTION STATE OF WISCONSIN ) ) COUNTY OF ____________)

Personally appeared before me this __________ day of ________________, 20_______, the above named

__and

_____

to me known to be the persons who executed the foregoing instrument in their respective capacities as officers of the aforenamed Cemetery Association and who acknowledged the same. + +

(Signature of Notary)

+ (Seal impression)

+

(Printed name of Notary)

My commission, issued by the State of

expires on

______

.

INSTRUCTIONS (Ref. sec. 157.062(6), Wis. Stats. for document content.)
Fee: There is no fee for filing the Cemetery Association Affidavit and Certificate of Reorganization. Delivery and Filing Procedure - Submit one original and one exact copy to: Mailing Address: Physical Address: Department of Financial Institutions Department of Financial Institutions Division of Corporate and Consumer Division of Corporate and Consumer Services Services PO Box 7846 345 W. Washington Ave., 3rd Floor Madison WI, 53707-7846 Madison WI 53703

Phone: 608-261-7577 Fax: 608-267-6813 TTY: 608-266-8818

The original will be filed and retained by the Department of Financial Institutions. The stamped duplicate will be returned to the name and address indicated on page 6 of the form 403. NOTICE: This form may be used to accomplish a filing required or permitted by statute to be made with the department. Information requested may be used for secondary purposes. This document can be made available in alternate formats upon request to qualifying individuals with disabilities. GENERAL INFORMATION: Annual Report Requirement: Cemetery Associations formed under sec. 157.062, Wis. Stats., are required to file an annual report with the Department of Financial Institutions. The report is due March 1st of each year. Report forms will be mailed about January 1st to the Association at its principal office address on record with the Department of Financial Institutions. Report forms may also be requested from the Department of Financial Institutions by contacting the Division Of Corporate and Consumer Services at (608)261-7577.

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Sec. 157.062(6) Wis. Stats.

CEMETERY ASSOCIATION AFFIDAVIT AND CERTIFICATE OF REORGANIZATION Return filed duplicate to: (Enter your name and return address below.)

Your phone number during the day: ( INSTRUCTIONS ­ continued

) ________-_____________.

Reorganization of a Cemetery Association - A Cemetery Association that was dissolved or was never properly organized may file for reorganization with the Department of Financial Institutions if it (1) has cemetery grounds in which human remains are buried and (2) has at least five members who are residents of the county in which its cemetery is located. The Association must first publish a Class III notice, pursuant to Chapter 985, in the municipality where the cemetery is located. The notice must state the time, place and purpose of the meeting to reorganize as a cemetery association. As part of the meeting, the Association must elect and classify trustees in accordance with the provisions of Sec. 157.062(1), Wis. Stats. The Association is reorganized when a copy of the proceedings of the reorganization meeting is delivered to the Department of Financial Institutions. Item 1: Indicate whether the Association was dissolved by failure to hold an annual election for three successive years or if the Association was never properly organized as a cemetery association. Select either A or B. Item 3: Enter the name of the Cemetery Association. Item 4: Enter the date the annual meeting of the Association will be held on each year. Item 5: Enter the principal office address of the Association. Item 6: Enter the name, business address and home address of at least 5 members of the Association. A schedule may be attached listing additional members. Item 7: Enter the date the meeting was held for the purpose of reorganizing the Association and electing the trustees. Item 8: Attach a copy of the proceedings from the meeting held for the purpose of reorganizing the Association and electing the trustees signed by the Secretary of the Association. Item 9: Enter the name, business address and home address of the individuals (not less than 3 nor more than 9) who were elected trustees of the Association. The trustees shall be divided into 3 classes who shall hold their offices for 1, 2 and 3 years respectively. Enter the date on which the terms expire. Item 9A: Strike the word "Optional" if the President, Secretary and Treasurer of the Association are identified in the trustees set forth in item 9. Item 10: Execution - This document must be executed by the chairperson and secretary of the Association in the presence of a Notary Public. The names of the chairperson and secretary should be stated in the Notary paragraph exactly as they appear in the document signatures in item 10. The Notary must also sign, apply his/her official seal and indicate the expiration date of his/her commission. EXCERPT ­ 1991 WISCONSIN ACT 269 157.062(9) Exemptions for Certain Nonprofit Cemeteries In lieu of delivering a certification, resolution or copy of proceedings to the Department of Financial Institutions, under sub. (1), (2) or (6)(b), a cemetery association that is not required to be registered under s.440.91(1) and that is not organized or conducted for pecuniary profit shall deliver the certification, resolution or copy of proceedings to the office of the register of deeds of the county in which the cemetery is located. Particulars on registration requirements under s.440.91(1) may be obtained from Department of Regulation and Licensing, Attn: Cemetery Regulation, PO Box 8935, Madison, WI 53707.
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