Free 45279.FH11 - Indiana

ANNUAL REPORT PURSUANT TO IC 30-2-13
State Form 45279 (R7 / 6-08) Approved by State Board of Accounts, 2008

Fiscal year ending

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STATE BOARD OF FUNERAL & CEMETERY SERVICE PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 (317) 234-3031 www.pla.IN.gov

INSTRUCTIONS:

1. Include the license fee (call or visit our website for current fees). 2. This report must be filed with the Board no later than ninety (90) days after the end of the establishment's fiscal year. 3.The information requested below shall be provided for the preceding fiscal year, as specified below.

* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it.

FOR OFFICE USE ONLY
Application fee License number issued Date fee paid (month, day, year) Date license issued (month, day, year) Receipt number License obtained by

DO NOT WRITE ABOVE THIS LINE
SECTION A
Mark applicable box:

Cemetery

Funeral Home

Perpetual Care Fund

Other seller (specify) __________________________________________
Certificate of authority number License / Registration number

1. Name, address and certificate of authority number (if applicable) of cemetery, funeral home, perpetual care fund or other seller.
Name of cemetery, funeral home, perpetual care fund or other seller Address (number and street, city, state, and ZIP code) Name of contact person Telephone number

(
Name of establishment Address (number and street, city, state, and ZIP code) Name of establishment Address (number and street, city, state, and ZIP code)

)

2. Name(s), address(es), and certificate of authority number(s) of the establishment(s) that will provide the services or merchandise (if different from above):
Certificate of authority number

Certificate of authority number

3a. If owner is a sole proprietorship, give the name and business address:
Name of sole proprietor Address of business (number and street, city, state, and ZIP code)

3b. If owner is a partnership, corporation or other non-natural person, give the name and address of:
i. Name of resident agent Address (number and street, city, state, and ZIP code) ii. Name of chief officer Address (number and street, city, state, and ZIP code)

4. If reporting for a cemetery, the amount of funds received by the owner during the previous fiscal year that are subject to the trust requirements set forth in IC 23-14-48 are required to be reported as follows: a. Amount of funds received for interment, entombment and columbarium niche rights sold: b. As set forth in 4a above, the combined liability pursuant to IC 23-14-48-3 of 15% or $.80 per square foot of ground interment rights sold, whichever is greater; 8% or $100.00 per entombment rights sold, whichever is greater; and a minimum of $20.00 per columbarium niche rights sold: c. Amount of funds actually placed in trust from sales reported in 4a above: $ $

$

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d. Name and address(es) of trustee(s):
Name of trustee Address (number and street, city, state, and ZIP code) Name of trustee Address (number and street, city, state, and ZIP code) Name of trustee Address (number and street, city, state, and ZIP code) Name of trustee Address (number and street, city, state, ZIP code)

e. If cemetery funds were not held in trust by a corporate trustee, give the name and address of the corporate surety and amount of trustee's bond required by IC 23-14-51:
Name of corporate surety Address (number and street, city, state, and ZIP code) Amount of trustee's fidelity bond

$

5a. If life insurance policies, annuity products, and amount(s) of money, or other property was received to fund pre-need contracts, give (answer all that apply):
i. Name of life insurance company(ies) issuing the policy(ies) or annuity products ii. The total amount of all policies, annuities, and/or money received on all pre-need contracts

$
iii. Identity of the property accepted 5b. Amount from 5a above, required to be placed in escrow 5c. Amount from 5b above, actually placed in trust or escrow:

$
Name Address (number and street, city, state, and ZIP code) Name Address (number and street, city, state, and ZIP code)

$

5d. Name and address of the trustee and/or name and address of the institution holding the escrow funds for amount set forth in 5c above.

CERTIFICATION / AFFIDAVIT STATE OF _______________________________ COUNTY OF _____________________________ SS:

I (We), _______________________________________________________, ________________________________________________________ and __________________________________________________________ of _____________________________________________________ do hereby affirm, under the penalties of perjury, that all of the information contained in this Annual Report is true and correct. I (we) understand that accurate books, records, and accounts, which support this information, must be maintained for three (3) years after the date of full performance of a contract. Violation of IC 30-2-13 may result in action being taken against me (us) by the State Board of Funeral and Cemetery Service. Subscribed and sworn to before me this ____________ day of __________________________________________, ____________.
Signature of owner / president / vice-president Signature of treasurer / secretary (if owner is not an individual) Signature of Notary Public Printed name of Notary Public Printed name of owner / president / vice-president Printed name of treasurer / secretary County of residence Date commission expires (month, day, year)

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