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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

Notification to Sell Prepaid Merchandise Contracts

NPM

Directions: Before selling prepaid merchandise contracts, 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. Please provide the following contact information regarding the Cemetery: a. ________________________________________________
Name of Legal Owner

________________________
E-mail Address

__________________
Phone Number

________________________________________________
Address

________________________
City

______
State

__________
Zip

b. _________________________________________________________________
Common Name of Cemetery

_________________________
County

________________________________________________
Physical Address

________________________
City

______
State

__________
Zip

c. _________________________________________________________________
Branch Establishment 1

_________________________
County

________________________________________________
Physical Address

________________________
City

______
State

__________
Zip

d. _________________________________________________________________
Branch Establishment 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. 16-329 1/1