Statutory Compliance Report Form - Funeral Homes Page 3
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35. Please complete the Oath and Compliance Report:
I, _________________________________________________________________, ___________________________, state that
Name of Funeral Home Owner or Officer
Title
______________________________________________________________________________________________________
Name of Funeral Home
is authorized to do business in the state of Kansas and is in compliance with Board of Mortuary Arts. Each customer has a separate account
in the name of the purchaser and seller, which is deposited within seven days of receipt into an approved Kansas financial institution or
credit union. No account balance has been paid out of any account until the corresponding merchandise has been delivered and the trustee
has been presented with a verified statement stating such.
I do hereby certify under penalty of perjury and pursuant to the laws of the state of Kansas that the information contained in this report
and supplied in any attachments thereto is true and correct and is a complete representation of all the prefinanced, prearranged funerals
for our firm. I am also willing to submit the books, records, papers and instruments of such funeral home to the examination and inspection
of the Secretary of State, pursuant to K.S.A. 16-310.
_________________________________________________
Signature
_________________________________________________
Printed Name of Owner or Officer
_________________________________________________
Title
_________________________________________________
Date
Rev. 4/1/09 nr
K.S.A. 16-310
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