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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

Statutory Compliance Report Funeral Homes

FH


Reporting Period _____/______/______ to _____/______/______ Funeral Home I.D. Number: _______________________

Directions: This report must be completed in full (typewritten or printed in ink), signed and filed within 60 days of request. If additional space is needed in answering any questions, please attach the information to this form as an Exhibit. Mail completed report to the Office of the Secretary of State.

1. Please provide the following contact information regarding the Funeral Home:

___________________________________________________
Name of Legal Owner

_______________________
E-mail Address

___________________
Phone Number

___________________________________________________
Address

__________________________
City

_____
State

_________
Zip

___________________________________________________
Name of Establishment

_______________________
E-mail Address

___________________
Phone Number

___________________________________________________
Address

__________________________
City

_____
State

_________
Zip

___________________________________________________
Name of Record Keeper

_______________________
E-mail Address

___________________
Phone Number

___________________________________________________
Address

__________________________
City

_____
State

_________
Zip

Check one: The legal owner is a: ____ Corporation ____ Partnership ____ LLC ____ Other (explain)________________________________________________________________________

2. Please answer the following Prearranged Agreement questions: a. Does the funeral home sell prearranged agreements, contracts or plans? ____ Yes ____ No
If no, skip to question 5.
b. Are ALL prearranged agreements, contracts or plans funded through insurance policies? ____ Yes ____ No
If yes, skip to question 5.


3. Attach a copy of the funeral home's last Board of Mortuary Arts report that details all agreements.

Rev. 4/1/09 nr

K.S.A. 16-310 1/3

4. Please fill out Authorization to Release Bank Statements Form (one custodian per page):

__________________________________________________________________________________________
Custodian of Trust Funds

_____________________________________________
Address

_________________________
City

_____
State

_________
Zip

The Secretary of State, or his representative, is proposing to conduct either an office or a field audit of our funeral home, pursuant to K.S.A. 16-310.
We hereby authorize the above-named bank/trust company to make available to the Secretary of State's office all information and records
relating to the following accounts:

Account Number

Account Name

__________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________

____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________

__________________________________________________________________________________________
Name of Funeral Home

_____________________________________________
Address

_________________________
City

_____
State

_________
Zip

________________________________________________________
Printed Name of Owner or Officer

______________________
Title

__________________________________________________________
Signature

______________________
Date

Rev. 4/1/09 nr

K.S.A. 16-310 2/3

5. Please complete the Oath and Compliance Report:

I, _________________________________________________________________, ___________________________, state that
Name of Funeral Home Owner or Officer Title

______________________________________________________________________________________________________
Name of Funeral Home

is authorized to do business in the state of Kansas and is in compliance with Board of Mortuary Arts. Each customer has a separate account in the name of the purchaser and seller, which is deposited within seven days of receipt into an approved Kansas financial institution or credit union. No account balance has been paid out of any account until the corresponding merchandise has been delivered and the trustee has been presented with a verified statement stating such. I do hereby certify under penalty of perjury and pursuant to the laws of the state of Kansas that the information contained in this report and supplied in any attachments thereto is true and correct and is a complete representation of all the prefinanced, prearranged funerals for our firm. I am also willing to submit the books, records, papers and instruments of such funeral home to the examination and inspection of the Secretary of State, pursuant to K.S.A. 16-310.

_________________________________________________
Signature

_________________________________________________
Printed Name of Owner or Officer

_________________________________________________
Title

_________________________________________________
Date

Rev. 4/1/09 nr

K.S.A. 16-310 3/3