Funeral Or Burial Funds Act Annual Forms Page 3
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11ANNUAL STATEMENT
Illinois Funeral or Burial Funds Act
License Number ___________________________________
Fiscal Year End Date________________________________
_________________________________________________
_________________________________________________
NAME OF LICENSEE
NAME OF BUSINESS
_________________________________________________
_________________________________________________
FEDERAL EMPLOYER IDENTIFICATION NUMBER; IF APPLICABLE
STATE OF ILLINOIS TAX IDENTIFICATION NUMBER; IF APPLICABLE
____________________________________________________________________________________________________________
NAME OF PRIMARY CONTACT PERSON
____________________________________________________________________________________________________________
BUSINESS LOCATION ADDRESS
CITY
STATE
ZIP CODE
COUNTY
____________________________________________________________________________________________________________
MAILING ADDRESS IF DIFFERENT THAN ABOVE
CITY
STATE
ZIP CODE
COUNTY
BUSINESS TELEPHONE (_____)___________________________________ FAX (_____) _____________________________ E-MAIL ADDRESS _____________________________________
Form of Ownership
( ) Association
( ) Sole Proprietorship
( ) Partnership
( ) Corporation
( ) Other ________________________________
Corporate Parent or Partnership (if applicable) _______________________________________________________________________
Corporate Contact Person _________________________________________________ Telephone Number ______________________
(Individual responsible for books and records)
___________________________________________________________________________________________________________________________________________________________________
BUSINESS ADDRESS OF CORPORATE PARENT
CITY
STATE
ZIP CODE
1. Please indicate if you are licensed under either of the following:
____ Illinois Cemetery Care Act
____ Illinois Pre-Need Cemetery Sales Act
2. Do you operate a Crematory? ____Yes ____No
If yes, list registration number _________________
3. Has there been a change in the ownership of the business location under this license number in the last 12 months?
____ Yes ____No
If yes, list date of the sale. ________________
4. Have you changed the form of ownership in the last 12 months?
____Yes ____No
Example: from Individual ownership to Corporate ownership
If yes, list date of change_______________ Changed to _______________
5. Have you changed the name of the licensee in the last 12 months? ____ Yes ____No
If yes, list date of change_______________ Changed to _______________
6. Have you changed trustees (independent or licensee) in the last 12 months? ____ Yes ____No
If yes, how many times? _______
If yes, please submit with this form a copy of a valid trust agreement if you have not yet done so.
7. In the last 12 months, has the licensee when acting as trustee changed custodians?
____ Yes ____No
8. Did you use a prepackaged computer application to generate the financial information necessary to complete this annual report?
____ Yes ____No
If yes, what is the name of the application?____________________________________________
9. During the last 12 months, have you factored, discounted, or sold to a third party installment basis pre-need contracts?
____ Yes ____No
FOR OFFICE USE ONLY- ILLINOIS FUNERAL OR BURIAL FUNDS ACT
Internal Code ________/__________/________
Fee Received ( ) Yes ( ) No
Received by_______________Date________
Postmark Date ________/________/_________
Check # ____________________ For $_______
Entered in full by___________Date________
3rd Party: ( ) IFDA ( ) FDSA ( ) SCI ( ) LGII
Verified by______________Date__________
Other ___________________________
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