Secretary of State State Capitol 500 East Capitol Avenue Pierre SD 57501-5070 Phone: 605-773-3537 Email: sdsos@state.sd.us Website: www.sdsos.gov For Office Use Only South Dakota Perpetual Care Licensed Banking Institution Report Contact Information Name of Cemetery Physical Location of Cemetery City Mailing Address Mailing City Mailing State Mailing Zip State Zip Person responsible for bookkeeping and records Email Owner Entity Type (select one) Corporation Phone Corporation ID (Ex: NS2345678) Non-Profit Fax Licensed Banking Institution Information Name of Licensed Banking Institution Address City Principal Account Number Earnings Account Number State Zip Signature (I certify that this report is true and correct to the best of my knowledge.) Date American LegalNet, Inc. www.FormsWorkFlow.com