State Form 45266 - Annual Report Of Funeral Trust Funds

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STATE BOARD OF FUNERAL & CEMETERY SERVICE

ANNUAL REPORT OF FUNERAL TRUST FUNDS

PROFESSIONAL LICENSING AGENCY

402 West Washington Street, Room W072

State Form 45266 (R3 / 7-08)

Indianapolis, Indiana 46204

(317)-234-3031

If additional space is required, please use a separate sheet of paper.

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Pursuant to IC 30-2-10-8, a funeral home, licensed under IC 25-15 that is named as beneficiary of funeral trust funds, shall annually report to the State

Board of Funeral and Cemetery Service; for the period of January 1, 20 ______ to December 31, 20 ______.

Name of funeral home

Funeral home license number

Address of funeral home (number and street, city, state, and ZIP code)

NAME AND ADDRESS OF ANY TRUSTEE WITH WHICH FUNERAL TRUST FUNDS ARE DEPOSITED FOR THE FUNERAL HOME

NAME OF TRUSTEE

ADDRESS

(number and street, city, state, and ZIP code)

NOTARY CERTIFICATE (SWORN OATH)

STATE OF ______________________________

SS:

COUNTY OF ____________________________