Pre-Need Establishment Registration Form - Mississippi Secretary Of State Page 3
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5Pre-Need Establishment Registration Form
Page Three
19. For initial filings, provide the number of pre-need contracts, by type, that were sold prior to
this registration.
Number Sold
Dollar Value
a) funded by trust
_____________
_____________
b) funded by insurance/annuity
_____________
_____________
c) evidenced by warehouse receipt
_____________
_____________
d) funded by insurance & trust
_____________
_____________
20. For initial filings, provide the number of pre-need contracts, by type, that were performed prior to
this registration.
Number Sold
Dollar Value
a) funded by trust
_____________
_____________
b) funded by insurance/annuity
_____________
_____________
c) evidenced by warehouse receipt
_____________
_____________
d) funded by insurance & trust
_____________
_____________
Annual Report Requirements
1. Have there been any changes in the investment of the assets of the trust, or changes in the trustee or trust
institution since the last report? If yes, attach a separate document reflecting all changes.
2. How many pre-need contracts, by type, were sold during the reporting year?
Number Sold
Dollar Value
a) funded by trust
_____________
_____________
b) funded by insurance/annuity
_____________
_____________
c) evidenced by warehouse receipt _____________
_____________
d) funded by insurance & trust
_____________
_____________
3. How many pre-need contracts, by type, were performed during the reporting year?
Number Sold
Dollar Value
a) funded by trust
_____________
_____________
b) funded by insurance/annuity
_____________
_____________
c) evidenced by warehouse receipt _____________
_____________
d) funded by insurance & trust
_____________
_____________
Rev. 5/2004
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