Ariz. Admin. Code § tit. 4, ch. 12, art. 5, app E

Download

PDF

Current through Register Vol. 30, No. 39, September 27, 2024

Appendix E - Annual Report

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

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.

__________________________________

__________________________________________

__________________________________

__________________________________________

__________________________________

__________________________________________

__________________________________

__________________________________________

__________________________________

__________________________________________

__________________________________

__________________________________________

__________________________________

__________________________________________

__________________________________

__________________________________________

__________________________________

__________________________________________

__________________________________

__________________________________________

__________________________________

SCHEDULE E SALESPERSONS TERMINATED DURING CALENDAR YEAR

Name

Registration No.

___________________________________________________

Ariz. Admin. Code tit. 4, ch. 12, art. 5, app E

Adopted effective January 1, 1985 (Supp. 85-1).