Statutory Compliance Report Form - Funeral Homes
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KANSAS SECRETARY OF STATE
Contact Information
FH
Statutory Compliance Report
Kansas Secretary of State
Audit Administrator
Funeral Homes
Memorial Hall, 1st Floor
120 S.W. 10th Avenue
Topeka, KS 66612-1594
(785) 296-1848
Reporting Period _____/______/______ to _____/______/______
Funeral Home I.D. Number: _______________________
Directions:
This report must be completed in full (typewritten or printed in ink), signed and filed within 60 days of request. If additional
space is needed in answering any questions, please attach the information to this form as an Exhibit. Mail completed report to the Office
of the Secretary of State.
1. Please provide the following contact information regarding the Funeral Home:
___________________________________________________
_______________________
___________________
Name of Legal Owner
E-mail Address
Phone Number
___________________________________________________
__________________________
_____
_________
Address
City
State
Zip
___________________________________________________
_______________________
___________________
Name of Establishment
E-mail Address
Phone Number
___________________________________________________
__________________________
_____
_________
Address
City
State
Zip
___________________________________________________
_______________________
___________________
Name of Record Keeper
E-mail Address
Phone Number
___________________________________________________
__________________________
_____
_________
Address
City
State
Zip
Check one: The legal owner is a:
____ Corporation
____ Partnership
____ LLC
____ Other (explain)________________________________________________________________________
2. Please answer the following Prearranged Agreement questions:
a. Does the funeral home sell prearranged agreements, contracts or plans? ____ Yes ____ No
If no, skip to question 5.
b. Are ALL prearranged agreements, contracts or plans funded through insurance policies? ____ Yes ____ No
If yes, skip to question 5.
3. Attach a copy of the funeral home’s last Board of Mortuary Arts report that details all agreements.
Rev. 4/1/09 nr
K.S.A. 16-310
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