Form Car - Cemetery Permanent Maintenance And Merchandise Trust Funds Annual Report Form - Secretary Of State Page 4

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4. Please fill out Authorization to Release Bank Statements Form:
________________________________________________________________________
Custodian of Trust Funds
_____________________________________________
_____________________________
_____
_________
Address
City
State
Zip
The Secretary of State, or his representative, is proposing to conduct either an office or a field audit of our cemetery, pursuant to K.S.A.
17-1312a and/or K.S.A. 16-325.
We hereby authorize the above-named bank/trust company to make available to the Secretary of State’s office all information and records
relating to the following accounts (cemeteries please include both permanent maintenance and merchandise trust fund account
information):
Account Number
Account Name
_____________________
____________________________________________________
_____________________
____________________________________________________
_____________________
____________________________________________________
_____________________
____________________________________________________
_____________________
____________________________________________________
_____________________
____________________________________________________
_____________________
____________________________________________________
_____________________
____________________________________________________
___________________________________________________________________________
Common Name of Cemetery
_____________________________________________
_____________________________
_____
_________
Address
City
State
Zip
________________________________________________
_____________________________
Printed Name of Owner or Officer
Title
________________________________________________
_____________________________
Signature
Date
K.S.A. 17-1312a; K.S.A. 16-329
Rev. 10/15/10 nr
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