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 Cemetery Annual Financial Report (For Preceding Fiscal year Due July 31 .) Contact Information Name of Cemetery Physical Location of Cemetery City Mailing Address Mailing City Mailing State Mailing Zip State Zip st Person responsible for bookkeeping and records Email Owner Entity Type (select one) Corporation Phone Corporation ID (Ex: NS2345678) Non-Profit Fax Principal Account (Not Including Earnings) Beginning Balance July 1 ­ (Must equal balance from June 30 of last year) st Earnings Account (Not Including Principal) Beginning Balance July 1st ­ (Must equal balance from June 30 of last year) Transfers from Principal Earnings Account (Must equal transfer to Earnings Account in the first column) Donations Other Income (Please List) + + Deposits from Sales + + +/+ + + + + + + + + Deposits from Donations Investment Earnings / Losses Other Income (Please List) Withdrawals / Expenses (Please List) - Care & Maintenance Expenses Other Expenses (Please List) - Transfer to Earnings Account' (Must be equal to or less than investment earnings) Ending Balance = Ending Balance = Note: No monies may be taken out of the principal fund to pay for the costs of administering the fund (SDCL 55-12-18). Please attach second page for any financial information that does not fit. Signature (I certify that this report is true and correct to the best of my knowledge.) Date American LegalNet, Inc. www.FormsWorkFlow.com