Form 49629 - Disclosure And Payment Of Prepaid Contracts Sold

Download a blank fillable Form 49629 - Disclosure And Payment Of Prepaid Contracts Sold in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 49629 - Disclosure And Payment Of Prepaid Contracts Sold with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

DISCLOSURE AND PAYMENT OF PREPAID

STATE BOARD OF FUNERAL & CEMETERY SERVICE

PROFESSIONAL LICENSING AGENCY

CONTRACTS SOLD

Reset Form

402 West Washington Street, Room W072

State Form 49629 (R / 6-08)

Indianapolis, Indiana 46204

(317) 234-3031

Approved by State Board of Accounts, 2008

INSTRUCTIONS:

1. Complete the requested information and remit with a check in the appropriate amount to the address above.

2. Make the check or money order payable to the Professional Licensing Agency.

3. Complete the Certification / Affidavit found on the reverse side of this form.

4. A SEPARATE FORM IS TO BE COMPLETED FOR EACH GEOGRAPHIC LOCATION OF A SELLER.

Pursuant to IC 30-2-13-27, no later than March 1st of each year, you are REQUIRED to make payment to the Prepaid Consumer Protection Fund for each

prepaid contract sold under IC 30-2-13 within the previous calendar year JANUARY 1 THROUGH DECEMBER 31. Failure to submit this report and make

the required payment may result in action being taken against you by the State Board of Funeral and Cemetery Service.

* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it.

FOR OFFICE USE ONLY

Application fee

Date fee paid (month, day, year)

Receipt number

License number issued

Date license issued (month, day, year)

License obtained by

DO NOT WRITE ABOVE THIS LINE

SECTION A

Mark applicable box:

Cemetery

Funeral home

Perpetual care fund

Other seller (specify) _________________________________________

Name of cemetery, funeral home, perpetual care fund or other seller

Certificate of authority number

Calendar year reporting

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

Name of contact person

Telephone number

E-mail address

(

)

Provide the following information pertaining to each person authorized to directly represent the seller as an agent (attach additional sheets if necessary).

NAME

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

SOCIAL SECURITY NUMBER *

Page 1 of 2