Form Cpn-2 - Pre-Need Burial Contract Annual Report Cover Sheet - Commonwealth Of Kentucky Office Of The Attorney General

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CPN-2
For Official Use Only
COMMONWEALTH OF KENTUCKY
DATE RECEIVED _________________
OFFICE OF THE ATTORNEY GENERAL
FEE PAID
_________________
1024 Capital Center Drive
DATE APPROVED _________________
Frankfort KY 40601-8204
APPROVED BY _________________
PRE-NEED BURIAL CONTRACT ANNUAL REPORT COVER SHEET
For the period ending December 31, 20____ (This report is due by 3/31 20____)
__________________________________________________________________________
__________________
Funeral Home Name
PNBL#
_______________________________________________________________________________________________
Location
_______________________________________________________________________________________________
Mailing Address
Attached is a true and correct report of activity in the pre-need funeral trust fund accounts that existed during the
calendar year. This report shows the activity in all of the trust fund accounts as of December 31 of the year for which
this report is filed: (1) all of the pre-need burial contracts that have ever been sold by this firm for which services have not
yet been performed and monies have not yet been refunded (that is, contracts that are still in existence on December 31 of
the year for which this report is filed); and (2) those pre-need burial contracts for which services were performed and/or
monies were refunded during the calendar year (that is, those accounts that had a positive balance on January 1, but show
a zero (0) balance as of December 31).
RECONCILIATION
Total Beginning Balance of Trust
$ ______________________
Deposits:
Total Additions
$ ___________________
Total Earnings
$ ___________________
Total Deposits
$ ______________________
Withdrawals:
Total Refunds/Conversions $ (___________________)
Total Serviced
$ (___________________)
Total Withdrawals
$ (_____________________)
Unrealized gains/losses from market changes
$ ______________________
Ending Balance of Trust
$ ______________________
I certify under penalty of law that I am authorized to complete this annual report form and that it represents, to the best of my
knowledge, an accurate accounting of all pre-need funds for the year for which this report is filed.
_______________________________________________________________________________________________
PRINT NAME
TITLE
SIGNATURE
Subscribed and sworn to me on this the ______ day of _________________, 20 _____.
___________________________________________
NOTARY PUBLIC
: _______________________________
MY COMMISSION EXPIRES

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