Fillable State Form 45279 - Annual Report Pursuant (Page 2 of 2) in pdf

State Form 45279 - Annual Report Pursuant Page 2

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d. Name and address(es) of trustee(s):

Name of trustee

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

Name of trustee

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

Name of trustee

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

Name of trustee

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

e. If cemetery funds were not held in trust by a corporate trustee, give the name and address of the corporate surety and amount of trustee's bond

required by IC 23-14-51:

Name of corporate surety

Amount of trustee's fidelity bond

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

5a. If life insurance policies, annuity products, and amount(s) of money, or other property was received to fund pre-need contracts, give (answer all that apply):

i. Name of life insurance company(ies) issuing the policy(ies) or annuity products

ii. The total amount of all policies, annuities, and/or money received on all pre-need contracts

iii. Identity of the property accepted

5b. Amount from 5a above, required to be placed in escrow

5c. Amount from 5b above, actually placed in trust or escrow:

5d. Name and address of the trustee and/or name and address of the institution holding the escrow funds for amount set forth in 5c above.

Name

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

Name

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

CERTIFICATION / AFFIDAVIT

STATE OF _______________________________

SS:

COUNTY OF _____________________________

I (We), _______________________________________________________, ________________________________________________________ and

__________________________________________________________ of _____________________________________________________ do hereby

affirm, under the penalties of perjury, that all of the information contained in this Annual Report is true and correct. I (we) understand that accurate books,

records, and accounts, which support this information, must be maintained for three (3) years after the date of full performance of a contract. Violation of

IC 30-2-13 may result in action being taken against me (us) by the State Board of Funeral and Cemetery Service.

Subscribed and sworn to before me this ____________ day of __________________________________________, ____________.

Signature of owner / president / vice-president

Printed name of owner / president / vice-president

Signature of treasurer / secretary (if owner is not an individual)

Printed name of treasurer / secretary

Signature of Notary Public

County of residence

Printed name of Notary Public

Date commission expires (month, day, year)

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