Fillable Disclosure-Disclaimer Form printable pdf download

DISCLOSURE-DISCLAIMER FORM

The Federal Trade Commission’s Funeral Industry Practices RULE requires certain disclosures and prohibits

misrepresentations. This Disclosure-Disclaimer Form is a checklist we ask those we serve to read and sign if during the

funeral arrangements our firm complied with the following:

Name of Deceased: ____________________________________________________________________________________

Date of Death: ________________________________________________________________________________________

Date of funeral and/or final disposition of body: _____________________________________________________________

The undersigned received a General Price List effective Aug. 1, 2016 prior to discussing prices, services, merchandise.

The undersigned received a Casket Price List effective Aug. 1, 2016 prior to viewing or discussing prices or caskets.

The undersigned received an Outer Burial Container Price List effective Aug. 1, 2016 prior to viewing or discussing

prices of outer burial containers.

The undersigned were not told that embalming is required by law and were told that the law does not require embalming

except in certain cases. If embalming was provided, it was done with the permission of the undersigned.

The undersigned were not told that any law requires embalming for direct cremations, immediate burial, or if

refrigeration is available and the funeral is without viewing or visitation.

The undersigned were informed that the law does not require a casket for direct cremation.

The undersigned were informed that the law does not require the purchase of an outer burial container.

The funeral home made no representations to the undersigned that embalming or the use of any merchandise available

from the funeral home would delay the decomposition of the remains for a long time or an indefinite time.

The undersigned understands that the funeral home has disclaimed all warranties with regard to caskets, outer burial

containers, and other merchandise sold by the funeral home. The undersigned further understands that the only

warranties, express or implied, granted in connection with the goods sold by the funeral home are the express written

warranties, if any, extended by the manufacturers of the goods. No other warranties, including the implied warranties of

the merchantability or fitness for a particular purpose are extended by the funeral home.

Done this __________________________________________________ day of ____________________, ______________

Witnessed:

Person(s) making final arrangements:

______________________________________________

___________________________________________

Funeral Director/Funeral Firm Provider

License #

Signature of Purchaser

Relationship

______________________________________________

___________________________________________

Date signed

Signature of Purchaser

Relationship

___________________________________________

Signature of Purchaser

Relationship

Disclosure-Disclaimer Form