Free 51264.FH11 - Indiana

RENEWAL OF CERTIFICATE OF AUTHORITY AND DISCLOSURE AND PAYMENT OF PREPAID CONTRACTS SOLD
State Form 51264 (R / 8-08) Approved by State Board of Accounts, 2008

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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

Application for a certificate of authority to sell prepaid services and merchandise in the State of Indiana in compliance with IC 30-2-13-33. Seller means a person, a firm, a limited liability company, a corporation, an association, or a partnership contracting to provide services or merchandise, or both, to a named individual or contracting to provide or sell both a contract and a funding mechanism to be used in conjunction with the purchase of services or merchandise. (IC 30-2-13-10) Renewal applications shall be filed by March 1st of each year.
* 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
Name of seller Business address of seller (number and street, city, state, and ZIP code) Certificate of authority number

I hereby affirm that the above named seller is of good moral character, operates using fair business practices, and has not been convicted of a criminal offense. SELLERS AGENTS The following persons have authority to directly represent the above named seller as agents (attach additional sheets, if necessary): NAME ADDRESS (number and street, city, state, and ZIP code) SOCIAL SECURITY NUMBER *

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REPORT OF PREPAID CONTRACTS Pursuant to IC 30-2-13-27, no later than March 1st of each year, you are REQUIRED to make payment to the Prepaid Consumer Protection Fund for each prepaid contract sold under IC 30-2-13 within the previous calendar year JANUARY 1 THROUGH DECEMBER 31. Failure to submit this report and make the required payment may result in action being taken against you by the State Board of Funeral and Cemetery Service. Instructions for disclosure and payment of prepaid contracts sold: 1. Complete the requested information and remit with a check in the appropriate amount, payable to Indiana Professional Licensing Agency. 2. A SEPARATE DISCLOSURE AND PAYMENT OF PREPAID CONTRACTS SOLD FORM IS TO BE COMPLETED FOR EACH GEOGRAPHIC LOCATION OF A SELLER. THE SEPARATE DISCLOSURE AND PAYMENT OF PREPAID CONTRACTS SOLD FORM, STATE FORM 49629, MAY BE OBTAINED ON OUR WEBSITE AT www.in.gov/pla. NUMBER OF PREPAID CONTRACTS SOLD PREPAID CONTRACTS SOLD AT A PURCHASE PRICE OF: NUMBER OF SALES X REQUIRED PAYMENT 1. $499.99 or less 2. $500.00 - $1499.99 3. $1500.00 or more X X X $2.50 $5.00 $10.00 TOTAL OF LINES 1 through 3 PAY THIS AMOUNT

= = = = $ $ $ $

TOTAL

0.00

Please check here if no prepaid contracts were sold in the previous calendar year January 1 through December 31: CERTIFICATION / AFFIDAVIT I hereby affirm that the statements herein are true and correct.
Signature of seller or partner or officer of seller Printed name of individual signing Title of individual signing Date (month, day, year)

STATE OF __________________________________________________

COUNTY OF _________________________________________________

}

SS:

I (we), __________________________________________________, _____________________________________________________________ and
(Owner / President / Vice President)

___________________________________ of ___________________________________________________________________________ do hereby
(Treasurer / Secretary) (Name of Establishment)

affirm, under the penalties of perjury, that all of the information contained in this disclosure is true and correct. I (we) understand that accurate books, records and accounts must be maintained which support this information for three (3) years after the date of full performance of a contract and that 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 this ___________ day of ______________________________, _____________.
Signature of Owner / President / Vice-President Signature of Treasurer / Secretary (if owner is not an individual) Signature of Notary Public My commission expires (month, day, year) Printed name of Owner / President / Vice-President Printed name of Treasurer / Secretary (if owner is not an individual) Printed name of Notary Public County of residence of Notary Public

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