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Kansas Secretary of State Audit Administrator
Memorial Hall, 1st Floor
120 S.W. 10th Avenue Topeka, KS 66612-1594 (785) 296-1848 [email protected]
www.kssos.org
Please complete the form, print, sign and mail to the Kansas Secretary of State. Selecting 'Print' will print the form and 'Reset' will clear the entire form. KANSAS SECRETARY OF STATE
Cemetery Registration
CER
Directions: This form must be completed in full (typewritten or printed in ink), signed and returned. If additional space is needed in answering any questions, please attach the information to this form as an Exhibit.
1. Please provide the following contact information regarding the Cemetery: _____________________________________________________
Name of Legal Owner
_______________________
E-mail Address
__________________
Phone Number
_____________________________________________________
Address
_______________________
City
______
State
__________
Zip
_____________________________________________________________
Common Name of Cemetery
___________________________________
County
_____________________________________________________
Physical Address
_______________________
City
______
State
__________
Zip
2. Please answer the following Cemetery questions: a. If incorporated, give state of incorporation: ___________________________ b. Give date of establishment: ___________________________ c. If incorporated outside of Kansas, give date granted authority in Kansas: ___________________________ d. Has the cemetery operated continuously since establishment? Yes ____ No ____ No ____
e. Is the cemetery a municipality or otherwise empowered to issue bonds or levy taxes? Yes ____
f. Does the cemetery constitute an established church and convey lots only to members and/or their relatives?
Yes ____ No ____
g. The legal owner is a: Cemetery organized as a for-profit corporation ______ Cemetery organized as a not-for-profit corporation ______ Cemetery organized for religious purposes ______ ______ Cemetery not a corporation Other (explain): _____________________________________________________________________________ h. Give amount currently in permanent maintenance trust fund: $___________________________ I do hereby certify under penalty of perjury and pursuant to the laws of the state of Kansas that the information contained in this form and supplied in any attachments thereto is true and correct. __________________________________________________________
Signature of Owner or Officer
________________________
Date
__________________________________________________________
Printed Name of Signer 6/15/07 nr
________________________
Title K.S.A. 17-1312a; K.S.A. 17-1312f 1/1