Form Wv/cem-4 - Preneed Cemetery Company Annual Report - 1999

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WEST VIRGINIA DEPARTMENT OF TAX AND REVENUE
INTERNAL AUDITING DIVISION
WV/CEM-4
OFFICE OF BUSINESS REGISTRATION
JUNE 1999
P.O. BOX 2666, CHARLESTON, WEST VIRGINIA 25330-2666
PRENEED CEMETERY COMPANY ANNUAL REPORT
WEST VIRGINIA IDENTIFICATION NUMBER, NAME AND ADDRESS
DUE DATE
FEIN
PERIOD COVERED
NAME
WITHIN FOUR
ADDRESS
MONTHS FOLLOWING
CITY ST ZIP
THE CLOSE OF THE
CEMETERY
Name and Mailing Address
FISCAL YEAR END
COMPANY'S FISCAL
YEAR
NAME
ADDRESS
CITY ST ZIP
A separate report must be completed for each trust account. Make a photocopy of this return for additional trust accounts. If more space is
needed for any item(s) on this report, attach additional sheet(s) and reference the appropriate line item (s).
1. Trust Account Name: . . . . . . . . . _______________________________________________________________
Where Located: . . . . . . . . . . . . . _______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2.
Compliance Agent Name: . . . . . _______________________________________________________________
Address: . . . . . . . . . . . . . . . . . . . _______________________________________________________________
_______________________________________________________________
Telephone Number: . . . . . . . . . . _______________________________________________________________
3.
Trustee Name: . . . . . . . . . . . . . . _______________________________________________________________
Address: . . . . . . . . . . . . . . . . . . . _______________________________________________________________
_______________________________________________________________
4.
Total amount of principal in preneed trust account: . . . . . . . . . . . . . . . . . . . . . . . . . . . .$____________________
5.
List securities in which trust account is invested:
NAME
AMOUNT INVESTED
WHEN INVESTED
DO NOT USE THIS SPACE

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