Agent Designation Certificate Form
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2AGENT DESIGNATION CERTIFICATE
MAIL TO:
Texas Department of Banking
UPON APPROVAL, THIS AGENT IS REPLACING:
Special Audits Division
2601 North Lamar Boulevard
____________________________________________
Austin, Texas 78705-4294
(NAME OF AGENT TO BE REMOVED)
This document requests the designation of the individual named below as an agent who is responsible for the funds
collected under contracts for prepaid funeral benefits under Section 154.160 of the Texas Finance Code. The designated
agent will be further authorized to certify documents requesting approval of the Department of Banking for withdrawal of
funds or release of benefits on deposit in prepaid funeral accounts, held on behalf of the contract beneficiary.
AGENT’S NAME: ______________________________________________
PERMIT NUMBER: ____________
PERMIT HOLDER NAME: __________________________________________________________________________
PERMIT HOLDER CITY: ____________________________________________________________________________
OWNER/PRESIDENT SIGNATURE: __________________________________________________________________
TYPED/PRINTED NAME AND TITLE OF OWNER/PRESIDENT: ___________________________________________________
I, _______________________________________, acknowledge appointment as an agent under the provisions of Section
(AGENTS NAME TYPED OR PRINTED)
154.160 of the Finance Code. I also certify that I have read page 2 of this form, and that I understand my responsibility as
a fiduciary under Section 32.45 of the Texas Penal Code.
___________________________________________
SIGNATURE OF AGENT
___________________________________________
TITLE OF AGENT
STATE OF _______________________
COUNTY OF _____________________
Before me, a notary public, on this day personally appeared ____________________________________, known to me to
be the person whose name is subscribed to the foregoing document, and, being by me first duly sworn, declared that
he/she has read and understands the statements herein contained and agree to comply with all laws as they relate to the
Finance Code.
Given under my hand and seal of office this _______ day of ________________________, A.D., ___________.
___________________________________________
NOTARY PUBLIC SIGNATURE
(SEAL)
___________________________________________
NOTARY PUBLIC TYPED OR PRINTED NAME
My commission expires: _______________________
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