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Get Ga Sec C13 2010-2024

SECURITIES AND BUSINESS REGULATION 2 Martin Luther King Jr. Drive S.E. Ste 802 West Tower Atlanta Georgia 30334 404 656-3920 http //www. sos. state. ga.us/securities/ Brian P. Kemp Secretary of State Robert D. Terry Division Director ANNUAL REPORT OF PRENEED DEALER FOR YEAR ENDING DECEMBER 31 2 PLEASE READ INSTRUCTIONS ACCOMPANYING THIS FORM. SECURITIES AND BUSINESS REGULATION 2 Martin Luther King Jr. Drive S*E* Ste 802 West Tower Atlanta Georgia 30334 404 656-3920 http //www. sos. state. ga*us/securities/ Brian P. Kemp Secretary of State Robert D. Terry Division Director ANNUAL REPORT OF PRENEED DEALER FOR YEAR ENDING DECEMBER 31 2 PLEASE READ INSTRUCTIONS ACCOMPANYING THIS FORM. This report is mandated by OCGA 10-14-12 g. PART I - GENERAL Registration Number Phone Number Name of Dealer Mailing Address City State Zip Code Location of Records Name and phone number of person to contact regarding this report PART II PRENEED ESCROW ACCOUNT Escrow Agent s Name Address Depository If more than one attach list with same information on each. Securities held being considered as a separate depository attach list showing cost and market Name Account Name Depository Activity - Attach additional sheets if necessary Total funds on deposit with Escrow Agent at beginning of year Add Total deposits made for the yearly activity Add Any other deposits made - attach explanation Add or Subtract Income increases/decreases to fund - attach explanation Subtotal lines 1 through 4 Subtract Escrow fees for year Subtract Depository fees for year Subtract Withdrawals - attach approval letter s copy of year-end statement from depository. Annual Preneed Escrow Account Liability Cumulative amount due to escrow account at beginning of the year Add Amount of deposits due to account for year s activities for sales and services attach copy of sales journal or detailed schedule. 12 Subtract Amount eligible for withdrawal from escrow account for yearly activities List only actual amount due to escrow - attach Form C-10 Cancellations and Deliveries earned PART III CERTIFICATION I hereby certify under penalties of perjury that the information contained in this Annual Report and the supporting documents attached hereto are true and correct to the best of my knowledge and belief* I further certify that all required deposits have been made to the preneed escrow account. I am authorized to sign this document on behalf of the individual or corporate owner. Signature Print Name Title Date Form C13 Revised Jan 2010. sos. state. ga*us/securities/ Brian P. Kemp Secretary of State Robert D. Terry Division Director ANNUAL REPORT OF PRENEED DEALER FOR YEAR ENDING DECEMBER 31 2 PLEASE READ INSTRUCTIONS ACCOMPANYING THIS FORM. This report is mandated by OCGA 10-14-12 g. PART I - GENERAL Registration Number Phone Number Name of Dealer Mailing Address City State Zip Code Location of Records Name and phone number of person to contact regarding this report PART II PRENEED ESCROW ACCOUNT Escrow Agent s Name Address Depository If more than one attach list with same information on each. .

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