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NOTIFICATION OF DESIGNATED TRUSTEE
State Form 48121 (R / 7-08)

STATE BOARD OF FUNERAL AND CEMETERY SERVICE PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072 Indianapolis, IN 46204-2700 Telephone: (317) 234-3031 www.pla.IN.gov

SECTION A (to be completed by the claimant or the claimant's representative)
Name of claimant

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

E-mail address

Telephone number

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SECTION B - DESIGNATED TRUSTEE INFORMATION (complete this section if the claimant is not deceased)
Name of trustee

)

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

License number

Certificate of authority number

Federal Identification number

SECTION C - BENEFICIARY INFORMATION (complete this section if claimant is deceased)
Name of beneficiary

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

Telephone number

(

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NOTARY CERTIFICATE STATE OF COUNTY OF

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SS:

I, _______________________________ do hereby state that I am the above-named Claimant/Claimant Representative (circle the appropriate choice), that I have personally completed the foregoing Notification, and the same is true to the best of my knowledge and belief.
Signature of claimant / claimant representative Signature of notary public

Printed name of claimant / claimant representative

Printed or typed name of notary public

Date (month, day, year)

County

Date commission expires (month, day, year)