5. Please complete the Oath and Compliance Report:
I, ____________________________________________________________, ________________________________, state that
Name of Cemetery Owner or Officer
Title
_____________________________________________________________________________________________________
Name of Cemetery
is authorized to do business in the state of Kansas pursuant to K.S.A. 17-1312a, and is in compliance with Kansas statutes concerning
trust funds. At least 15 percent of the purchase price for a grave space or at minimum $25.00 is placed, within 45 days of receipt, into an
approved Kansas financial institution. No part of the principal has been paid out without written permission from the Kansas Secretary
of State and no part has been used to make loans to stockholders, the corporation, the individual proprietor or the partner.
At least 110 percent of the wholesale cost for a prepaid merchandise contract is placed, within 10 days of receipt, into an authorized Kansas
financial institution. No part of the principal has been paid out 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 Annual
Report and supplied in any attachments thereto is true and correct, and am willing to submit the books, records, papers and instruments
of such cemetery to the examination and inspection of the Secretary of State, pursuant to K.S.A. 17-1312c.
________________________________________________
Signature of Owner or Officer
________________________________________________
Printed Name
________________________________________________
Title
________________________________________________
Date
K.S.A. 17-1312a; K.S.A. 16-329
Rev. 10/15/10 nr
5/5
1
2
3
4
5
