Free 45269.FH11 - Indiana

APPLICATION FOR FUNERAL HOME RESTORATION
State Form 45269 (R / 4-03) Approved by State Board of Accounts, 2003

State Board of Funeral and Cemetery Service 302 W. Washington St., Rm. E034 Indianapolis, IN 46204 Telephone: (317) 232-2980 www.in.gov/pla

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Fee

Federal ID number is requested as stated in IC 4-1-8-1; disclosure is mandatory. The number will be given to the Department of Revenue.

License number

Name of funeral home Address of funeral home (number and street) (city, state, ZIP code) Telephone number (check applicable category) sole proprietor partnership corporation Address (number and street, city, state,ZIP code) Principal address of residence of sole proprietor (number and street, city, state, ZIP code) Names, titles and principal addresses of residence of the partners, directors or other executive officers: Name Title Address (number and street, city, state, ZIP code) Name Title Address (number and street, city, state, ZIP code) Federal ID number * Name of sole proprietor (if applicable)

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

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

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

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

Name of the manager in charge of the funeral home

License number of funeral director

Names and license numbers of all funeral directors/embalmers and funeral director interns who will be performing services at or on behalf of the funeral home:
Name Name Name Name License number License number License number License number

(Continued on the reverse side)

Undersigned acknowledges as the applicant, or on behalf of the applicant, that the funeral home may not be operated without having a funeral director either perform or directly supervise each act of funeral service performed for the funeral home. Undersigned swears to or affirms the truth of the foregoing.
Signature of applicant or applicant's agent Title of the signed agent if applicant

NOTARY CERTIFICATE (SWORN OATH) STATE OF COUNTY OF I,

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SS:

, having been duly sworn on oath, say that I am the

above-named applicant, that I have personally prepared the foregoing application, and that the same is true to the best of my knowledge and belief.
Signature of applicant Printed or typed name of applicant Date subscribed and sworn to Notary Public Signature of Notary Public Printed or typed name of Notary Public County of residence Date commission expires

(If additional space is required, use the area below)