Dave Freudenthal THE STATE OF WYOMING Governor
Insurance Department Ken Vines Commissioner th106 East 6 Avenue ? Cheyenne, Wyoming 82002
PRIVATELY OWNED CEMETERY
ANNUAL REPORT FOR YEAR ENDED 2010
Pursuant to Wyoming Regulations, Chapter 28, Section 12, each seller shall file an annual report with the
commissioner on or before March 1. Pursuant to Section 14, “Any person who shall violate any of the provisions of
these Privately Owned Cemetery Regulations, or make any false or fraudulent report required under the provisions of
these regulations shall be punishable in accordance with W.S. ? 26-1-107 and W.S. ? 35-8-105.” Please complete the following and return to the attention of the Wyoming Insurance Department, Examination Section.
BUSINESS PHONE NO.: FAX NO.
E-Mail Address: ______________________________________ Name of Perpetual Care
Principal Balance December 31, 2009: $ (a)
Add Deposits Calendar Year 2010:
Number of Lots Sold $ (b)
Number of Crypts Sold $ (c)
Number of Inurnment Niches $ (d)
TOTAL (a) through (d) $ _________________ Total number of dispositions (interments,
entombments and inurnments) during 2010 ___________
Administration (307) 777-7401 ? Fax (307) 777-2446 http://insurance.state.wy.us. Licensing (307) 777-7319 ? Fax (307) 777-5895 G:Clerical/Forms/Company/Cemas10 Page 1 of 2
Include the following attachments to this report:
Attachment A - Full name and address (both residence and place of business) of the seller and every member, officer, and director thereof.
Attachment B - Detailed statement of the seller's assets and liabilities.
Attachment C - Detailed accounting of all transactions, dates and amount of payments made and accepted thereon.
Attachment D - Name and address of each buyer.
Attachment E - Name of the decedent as to each contract of sale for a lot, crypt or niche.
Attachment F - Total amount of perpetual care funds invested in each of the investments authorized by the commissioner of the Wyoming Insurance Department.
Attachment G - Number of interments or entombments for the year.
Attachment H - Detailed statements of how the seller plans to provide for the perpetual care of the cemetery.
Attachment I - Copy of surety bond.
Attachment J - Submit annual trust statement from your depository unless in a master trust.
I hereby certify that the foregoing information, including Attachments A, B, C, D, E, F, G, H, I and J, is a full, true and correct reporting of the accounts and records for the calendar year ending December 31, 2010.
(Officer or Director)
Subscribed and sworn to before me this day of , 20___.
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