Funeral Or Burial Funds Act Annual Forms (Page 10 of 11) in pdf

INDEPENDENT TRUSTEE CERTIFICATION

If licensee has more than one Independent Trustee this form should be copied, completed and notarized for each Independent Trustee.

I, the undersigned ________________________________________, Independent Trustee of the investments for

(Name of Licensee) ______________________________________________as listed on page _____ of this Annual

Report as of (date)___________________________________, ____________ being first duly sworn, state that the

enclosed information is correct to the best of my knowledge.

Please indicate whether or not the bank or trust company provided is a corporate fiduciary (check one):

Corporate Fiduciary

Non-Corporate Fiduciary

By checking “Corporate Fiduciary”, the endorser attests that the bank or trust company provided herein is a corporate fidu-

ciary as defined under the Corporate Fiduciary Act (205 ILCS 620).

__________________________________________

SIGNATURE

_________________________________________________________

NAME OF BANK or TRUST COMPANY

Subscribed and sworn to before me in ____________________________ County, in the State of Illinois by the said

____________________________________ who personally appeared before me in the aforesaid County and State,

this ______________________________________ day of ______________________, _________ .

_________________________________________________

NOTARY PUBLIC

My commission expires______________________________

NOTARY SEAL

LICENSEE CERTIFICATION

All licensees must complete this section of the report and have it notarized.

I, the undersigned (owner, officer, partner, trustee) _________________________________________________

of (Name of Licensee)___________________________________________________________ being duly sworn,

state that I have examined this Annual Statement for the year ending _________________________ , __________

and that all information included in this statement is correct to the best of my knowledge and fully complies with all

provisions of the Illinois Funeral or Burial Funds Act, 225 ILCS 45/1, et seq.

I further understand that violations of provisions of the above Act may constitute a Class 4 felony.

______________________________________________________ ____________________________________

NAME

TITLE

______________________________________________________ ____________________________________

SIGNATURE

DATE

Subscribed and sworn to before me in_________________________________County, in the State of Illinois by the

said________________________________________who personally appeared before me in the aforesaid County

and State, this ____________________________ day of ___________________________, _________________ .

_________________________________________________

NOTARY PUBLIC

My commission expires______________________________

NOTARY SEAL

Page 9 of 10

Funeral Or Burial Funds Act Annual Forms Page 10