Arizona Administrative Code › Title 4 - PROFESSIONS AND OCCUPATIONS › Chapter 12 - Board of Funeral Directors and Embalmers › Article 5 - PREARRANGED FUNERAL AGREEMENTS › Appendix E - Annual Report

Current through Register Vol. 30, No. 28, July 12, 2024
ANNUAL REPORT
For Calendar Year Ending ____________
Name of Establishment
				  ____________________________________________________________________________________________
Address________________________________________________________________________________________________________
___________________________________________________________________________________________
				  Zip ________________
Owners (owning a 10 percent or greater interest in the
				  Establishment):
Name:____________________________________________
				  Name:_______________________________________________
Address:___________________________________________
				  Address:_____________________________________________
____________________________________________
				  ______________________________________________
Name:____________________________________________
				  Name:_______________________________________________
Address:___________________________________________
				  Address:_____________________________________________
____________________________________________
				  ______________________________________________
Funeral Establishment License No. ________________ Issued
				  ________________
AFFIDAVIT
State of __________________
County ___________________
__________________________, being first duly sworn and upon
				  [my] [our] oath, depose and state:
[I am] [We are] the owner(s) of ( establishment ) on behalf
				  of which [I] [we] make this affidavit, being hereunto duly authorized. The
				  funeral establishment herein named has complied with title 32, Chapter 12,
				  Article 5 of the Arizona Revised Statues and the rules adopted pursuant to said
				  Article. This Annual Report includes all prearranged funeral agreements sold or
				  administered by this establishment. [I] [We] have read this Annual Report and
				  accompanying Schedules A, B, C, D and E and know the contents thereof, and the
				  matters and things therein stated are true and correct.
Subscribed and sworn to before me this ______ day of
				  _______________, 19 _____.
_____________________________
Notary Public
5724A19 page 1
SCHEDULE A Page ______
PREARRANGED FUNERAL SALES DURING
						  CALENDAR YEAR ENDING ______________
Financial Institution Name
						  ____________________ Address ___________________________________ Trust Account
						  No.(s)*________________________
PURCHASER NAME AND ADDRESS
SALE DATE
SALES PERSON
BENEFICIARY
TOTAL CONTRACT AMOUNT
INITIAL SERVICE FEE
INITIAL SERVICE FEE PAID
TOTAL MONIES PAID BY PURCHASER
TOTAL MONIES TO TRUST ACCOUNT
TOTAL REFUNDS MADE
BANK SERVICE CHARGES
OTHER WITH-DRAWALS (EXPLAIN)**
12/31 TRUST ACCOUNT BALANCE
Page Totals
TOTALS
* If this schedule concerns a
						  number of trust accounts, provide names and addresses of financial institutions
						  and list account numbers on separate sheet. ** If other withdrawals have
						  occurred, explain in detail on separate sheet. 5806A1
page 2
SCHEDULE B Page ______
EXISTING PREARRANGED FUNERAL
						  AGREEMENTS SOLD BEFORE CALENDAR YEAR ENDING ______________
Financial Institution Name
						  ____________________ Address ___________________________________ Trust Account
						  No.(s)*________________________
PURCHASER NAME AND SALE DATE
TOTAL CONTRACT AMOUNT
INITIAL SERVICE FEE
INITIAL SERVICE FEE PAID
TOTAL MONIES PAID BY PURCHASER
						  THIS YEAR
TOTAL MONIES PAID BY PURCHASER
TOTAL MONIES TO TRUST ACCOUNT
TOTAL REFUNDS PAID
ANNUAL SERVICE FEE
TAXES PAID
BANK SERVICE CHARGES
OTHER WITH-DRAWALS (EXPLAIN)**
12/31 TRUST ACCOUNT BALANCE
* If this schedule concerns a
						  number of trust accounts, provide names and addresses of financial institutions
						  and list account numbers on separate sheet. ** If other withdrawals have
						  occurred, explain in detail on separate sheet. 5086A2
page 3
SCHEDULE C Page ______
Financial Institution Name
						  ____________________ Address ___________________________________ Trust Account
						  No.(s)*________________________
SUMMARY OF TRUST ACCOUNT
						  TRANSACTIONS FOR CALENDAR YEAR ENDING _______________
Total trust funds in account(s)
						  on December 31 of previous calendar year.
$ ______
$ ______
Total funds received and
						  deposited in trust account(s) during this calendar year.
$ ______
Total funds withdrawn from
						  trust account(s) during this calendar year:
1) Funeral arrangements 2)
						  Annual service fees 3) Tax payments 4) Financial institution service charges 5)
						  Refunds to purchasers 6) Other withdrawals** TOTAL WITHDRAWALS
$ ______ $ ______ $ ______ $
						  ______ $ ______ $ ______
$ ______
Total interest paid to trust
						  account(s) during this calendar year.
$ ______
Total trust funds in account(s)
						  on December 31 of this calendar year.
$ ______
Total funds received for trust
						  but not deposited in trust account(s) as of December 31 of this calendar year.
$ ______
SCHEDULE D SALESPERSONS EMPLOYED
						  OR ENGAGED DURING CALENDAR YEAR
Name
Address
Registration No.
__________________________________
__________________________________________
__________________________________
__________________________________
__________________________________________
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SCHEDULE E SALESPERSONS
						  TERMINATED DURING CALENDAR YEAR
Name
Registration No.
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
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