Certificate Of Cancellation And Application For Withdrawal Trust-Funded Prepaid Funeral Contract Form

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CERTIFICATE OF CANCELLATION AND APPLICATION FOR WITHDRAWAL

TRUST-FUNDED PREPAID FUNERAL CONTRACT

To (Depository) ________________________________________________________________________________________

From (Seller) Name

______________________________

Permit Number: _______________________________

Address

______________________________

Prepaid Contract #: ____________________________

City, State, Zip ______________________________

Date of Contract: ______________________________

Telephone/Fax ______________________________

Principal on Deposit $___________ Accrued Income $____________ Total to be Withdrawn $______________________

Contracts sold after September 1, 2001, total to be refunded to purchaser $___________

(principal plus one-half of any accrued interest).

The purchaser and the seller have agreed to cancel the prepaid funeral contract and are requesting a withdrawal of the funds on

deposit for this contract. Therefore, the depository is authorized to release and pay same as indicated above.

Purchaser

Your signature on this application for withdrawal indicates your desire to receive a cash refund on your prepaid funeral benefit contract and to

cancel the prearranged funeral. You should receive your refund within 30 days of the Seller receiving the written notice.

If you cancel your prepaid contract WITHIN ONE YEAR of signing it, when your payments are current, the Seller is required to refund the greater

of: (1) 90% of the actual amount of money you paid; or

(2) the amount of money the Seller has deposited into the approved financial institution for your contract. The money deposited for your

contract does not include the amount the seller can keep. Read the payment terms section of the prepaid contract for the amount of money

that will be deposited for you.

If you cancel your prepaid contract AFTER THE FIRST YEAR, you will receive the amount you have paid, less the amount the Seller can keep.

In addition, for any contract that was sold after September 1, 2001, the purchaser is also entitled to receive one-half of the interest earned on it. For

contracts sold before September 1, 2001, the purchaser is not entitled to the interest.

If you cancel the contract at the request of the Seller, then the Seller is required to refund all money paid and the income earned.

If you are not the original purchaser of the funeral contract, you must provide legal documentation to the Seller that you have the authority to

request this cancellation. If you have any complaints concerning the cancellation of your prepaid funeral contract, you may contact the Texas

Department of Banking, Special Audits Division, toll-free at (877) 276-5554.

If you are canceling this contract and applying your refund to another contract from the same seller, you MUST initial this paragraph as

indication that you acknowledge your refund will be applied directly to your new contract and no refund will be issued.

(Initial here: _____________)

___________________________________________________________

______________________________________________________

Signature of Purchaser

Date

___________________________________________________________

______________________________________________________

Street Address

City, State, Zip

STATE OF ______________________

COUNTY OF ____________________

________________________________________, the purchaser, personally appeared before me and being first duly sworn, declared he/she signed

this application in the capacity designated and stated he/she has read the application and that the statements in the application are true and correct.

Sworn to and subscribed before me this ________ day of _____________________________, 20_____.

_________________________________________________

____________________________________________

Signature of Notary Public

Date Commission Expires

SELLER

______________________________ (Seller) certifies that the amount shown on this application for withdrawal represents the allowable amount to

be withdrawn under the provisions of Section 154.155 of the Texas Finance Code. To my knowledge, neither I nor any of my agents encouraged or

solicited the customer to cancel this contract.

_______________________________________________________________

_______________________________

Signature of Seller’s Approved Designated Agent