Free PMF - Kansas

Print

Reset

Contact Information
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

Notice of Intent to Sell Prearranged Funeral Agreements, Contracts or Plans

NPF

Directions: Before engaging in such prearranged agreements, contracts or plans, this form must be completed in full (typewritten or printed in ink) and signed. If additional space is needed in answering any questions, please attach the information to this form as an Exhibit.


1. If you intend to sell prearranged funeral agreements, contracts or plans, please provide the following contact information regarding the Funeral Home: a. ________________________________________________
Name of Legal Owner

________________________
E-mail Address

__________________
Phone Number

________________________________________________
Address

________________________
City

______
State

__________
Zip

b. _________________________________________________________________
Principal Place of Business

_________________________
County

________________________________________________
Physical Address

________________________
City

______
State

__________
Zip

c. _________________________________________________________________
Name of Branch Location 1

_________________________
County

________________________________________________
Physical Address

________________________
City

______
State

__________
Zip

d. _________________________________________________________________
Name of Branch Location 2

_________________________
County

________________________________________________
Physical Address

________________________
City

______
State

__________
Zip

e. _________________________________________________________________
Financial Institution/Trustee 1

_________________________
County

________________________________________________
Physical Address

________________________
City

______
State

__________
Zip

f.

_________________________________________________________________
Financial Institution/Trustee 2

_________________________
County

________________________________________________
Physical Address

________________________
City

______
State

__________
Zip

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. 16-310(e) 1/1