ANNUAL REGISTRATION STATEMENT - ENDOWMENT CARE CEMETERY ACT Idaho Department of Finance 700 W. State St., 2nd Fl., Boise, ID 83702 P.O. Box 83720, Boise, ID 83720-0031 Telephone: 208/332-8004 Facsimile: 208/332-8099 Internet Address: finance.idaho.gov 1. Name of cemetery authority 2. Address 3. Date of organization 4. Location of books and records 5. Board of directors 6. Trustee 7. Location of trust funds 8. Market value of the care funds held by the trustee of said cemetery authority at beginning of year or fiscal period $ Date: ADDITIONS TO SAID FUNDS DURING the calendar year or fiscal year from the following sources: a) Under and by virtue of the sale of lots, graves, crypts, or niches b) Under and by virtue of any gift, grant devise, bequest, payment or other contributions Income received from such funds during the preceding calendar or fiscal year Unrealized gains or losses for period $ c) d) LESS COST of administering fund LESS FUNDS used solely for the general care, maintenance, etc. TOTAL MARKET VALUE of the care funds held by the trustee 9. 10. The securities in which such care funds are invested (attach separate detailed listing, showing actual cost $ $ $ $< $< $ > > $ Detail of the proceeds added to the TRUST FUND during calendar or fiscal year. a) Number (_______) of adult ground burial spaces sold and paid to fund b) c) d) e) Number (_______) of infant burial spaces sold Number (_______) of niches sold Number (_______) of crypts sold LESS FUNDS received during the past 30 days but not yet deposited to said trust fund Transfer TOTAL to 8a $ $ $ $ $< $ > American LegalNet, Inc. www.USCourtForms.com STATE OF IDAHO County of ) ) ss. ) BEFORE ME, the undersigned authority of this day personally appeared and known to me to be the President and Secretary, respectively, (or two of the responsible officers) of (name of cemetery) and being by me duly sworn on oath did depose and say, each for himself (or herself) that each of the affiants has read the above and foregoing report of status of Care Funds of said Cemetery, that each knows the contents thereof, and that the facts set forth therein are known by each of said affiants to be in all things true and correct. (Affiant) President (Affiant) Secretary SUBSCRIBED AND SWORN TO before me this __________ day of ______________, 20____ to certify which witness my hand and seal of office. Notary Public: Residing at: My Commission expires: American LegalNet, Inc. www.USCourtForms.com