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
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. | ||||||||||
| __________________________________ | __________________________________________ | __________________________________ | ||||||||||
| __________________________________ | __________________________________________ | __________________________________ | ||||||||||
| __________________________________ | __________________________________________ | __________________________________ | ||||||||||
| __________________________________ | __________________________________________ | __________________________________ | ||||||||||
| __________________________________ | __________________________________________ | __________________________________ | ||||||||||
| __________________________________ | __________________________________________ | __________________________________ | ||||||||||
| __________________________________ | __________________________________________ | __________________________________ | ||||||||||
| __________________________________ | __________________________________________ | __________________________________ | ||||||||||
| __________________________________ | __________________________________________ | __________________________________ | ||||||||||
| __________________________________ | __________________________________________ | __________________________________ | ||||||||||
| SCHEDULE E SALESPERSONS TERMINATED DURING CALENDAR YEAR | ||||||||||||
| Name | Registration No. | |||||||||||
| ___________________________________________________ | ___________________________________________________ | |||||||||||
| ___________________________________________________ | ___________________________________________________ | |||||||||||
| ___________________________________________________ | ___________________________________________________ | |||||||||||
| ___________________________________________________ | ___________________________________________________ | |||||||||||
| ___________________________________________________ | ___________________________________________________ | |||||||||||
| ___________________________________________________ | ___________________________________________________ | |||||||||||
| ___________________________________________________ | ___________________________________________________ | |||||||||||
| ___________________________________________________ | ___________________________________________________ | |||||||||||
| ___________________________________________________ | ___________________________________________________ | |||||||||||
