Free 45266.FH11 - Indiana

ANNUAL REPORT OF FUNERAL TRUST FUNDS
State Form 45266 (R3 / 7-08)

STATE BOARD OF FUNERAL & CEMETERY SERVICE PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 (317)-234-3031 www.pla.IN.gov

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Pursuant to IC 30-2-10-8, a funeral home, licensed under IC 25-15 that is named as beneficiary of funeral trust funds, shall annually report to the State Board of Funeral and Cemetery Service; for the period of January 1, 20 ______ to December 31, 20 ______.

Name of funeral home

Funeral home license number

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

NAME AND ADDRESS OF ANY TRUSTEE WITH WHICH FUNERAL TRUST FUNDS ARE DEPOSITED FOR THE FUNERAL HOME NAME OF TRUSTEE ADDRESS (number and street, city, state, and ZIP code)

NOTARY CERTIFICATE (SWORN OATH) STATE OF ______________________________ SS: COUNTY OF ____________________________ I, ___________________________________________________, having been duly sworn on oath, say that I am the acting representative of the above named funeral home, that I have personally prepared the foregoing report, and that the same is true to the best of my knowledge and belief.
Signature of acting representative of funeral home Date subscribed and sworn (month, day, year)

Printed or typed name of acting representative

Title of acting representative of funeral home

Signature of Notary Public

County of residence

Printed or typed name of Notary Public

Date commission expires (month, day, year)