Fillable State Form 45279 - Annual Report Pursuant printable pdf download

ANNUAL REPORT PURSUANT

Fiscal year ending

STATE BOARD OF FUNERAL & CEMETERY SERVICE

PROFESSIONAL LICENSING AGENCY

TO IC 30-2-13

402 West Washington Street, Room W072

Indianapolis, Indiana 46204

State Form 45279 (R7 / 6-08)

Reset Form

(317) 234-3031

Approved by State Board of Accounts, 2008

INSTRUCTIONS:

1. Include the license fee (call or visit our website for current fees).

2. This report must be filed with the Board no later than ninety (90) days after the end of the establishment's fiscal year.

3.The information requested below shall be provided for the preceding fiscal year, as specified below.

* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory and this record cannot be processed without it.

FOR OFFICE USE ONLY

Application fee

Date fee paid (month, day, year)

Receipt number

License number issued

Date license issued (month, day, year)

License obtained by

DO NOT WRITE ABOVE THIS LINE

SECTION A

Mark applicable box:

Cemetery

Funeral Home

Perpetual Care Fund

Other seller (specify) __________________________________________

1. Name, address and certificate of authority number (if applicable) of cemetery, funeral home, perpetual care fund or other seller.

Name of cemetery, funeral home, perpetual care fund or other seller

Certificate of authority number

License / Registration number

Address (number and street, city, state, and ZIP code)

Name of contact person

Telephone number

(

)

2. Name(s), address(es), and certificate of authority number(s) of the establishment(s) that will provide the services or merchandise (if different from above):

Name of establishment

Certificate of authority number

Address (number and street, city, state, and ZIP code)

Name of establishment

Certificate of authority number

Address (number and street, city, state, and ZIP code)

3a. If owner is a sole proprietorship, give the name and business address:

Name of sole proprietor

Address of business (number and street, city, state, and ZIP code)

3b. If owner is a partnership, corporation or other non-natural person, give the name and address of:

i. Name of resident agent

Address (number and street, city, state, and ZIP code)

ii. Name of chief officer

Address (number and street, city, state, and ZIP code)

4. If reporting for a cemetery, the amount of funds received by the owner during the previous fiscal year that are subject to the trust requirements set

forth in IC 23-14-48 are required to be reported as follows:

a. Amount of funds received for interment, entombment and columbarium niche rights sold:

b. As set forth in 4a above, the combined liability pursuant to IC 23-14-48-3 of 15% or $.80 per

square foot of ground interment rights sold, whichever is greater; 8% or $100.00 per entombment

rights sold, whichever is greater; and a minimum of $20.00 per columbarium niche rights sold:

c. Amount of funds actually placed in trust from sales reported in 4a above:

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