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a o 2021 PRENEED FUNERAL TRUST FUND REPORT (California)

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CALl~ORNIA
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DEPARTMENT
OF
CONSUMER
AFFAIRS
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
CEMETERY AND FUNERAL BUREAU
1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834
P 916.574.7870 F 916.928.7988 www.cfb.ca.gov
(Read the instructions beginning on Page 8 before completing this report.)
2021 PRENEED FUNERAL TRUST FUND REPORT
FUNERAL ESTABLISHMENT:
LICENSE NUMBER: FD
ADDRESS:
Check One
Current Report
Final Report
OTHER
January 1, 2021 to December 31, 2021
Period Beginning _______________ to Period Ending _____________
Period Beginning _______________ to Period Ending _____________
IMPORTANT
1. This report must be filed with the Cemetery and Funeral Bureau on or before May 1, 2022. The fee for
timely filing is $200.00.
2. Any report received or postmarked after May 1, 2022, will be deemed to be late. The fee for late filing is
$300.00.
3. A final preneed trust fund report is required upon the transfer of license or cessation of business. A final
report, and the applicable report fee, must accompany the Application for Assignment of Funeral
Establishment License. Reporting forms will be mailed upon request.
4. Two (2) or more funeral establishments who utilize a common trust fund may cause the trustees of the
fund to file one (1) combined report. A combined report must disclose each funeral establishment's
summary of trust transactions (page 4) separately. The fee for timely filing of a combined report is
$200.00 and for a late report is $300.00.
FOR
OFFICIAL USE ONLY
Reviewer:_________ Date Received:_______
__p/c __b/c __m/o __csh
Date:_________ Amount:___________
Receipt No:__________
(Read the instructions beginning on Page 8 before completing this report.)
21 P-4a
1
2021
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QUESTIONNAIRE
1. Type of Business Organization:
Individual Partnership Corporation
2. Are you also a licensed cemetery authority?
YES NO
3. Is this trust active (i.e., receiving payments and/or adding new trustors) ?
YES NO
If yes, please attach a blank copy of the current trust agreement to this report.
4. How are trust funds invested?
Individual Passbooks
Commingled Savings
Commingled Investments Other
Explain)
5. Is the entire corpus returned upon revocation?
YES NO (If NO, please explain.)
6. Are requests for revocation honored within 15 days?
YES NO (If NO, please explain.)
7. Were any investments in default for more than sixty (60) days?
YES NO (If YES, please explain.)
8. Have individual beneficiary ledger accounts been established?
YES NO (If NO, please explain.)
9. Do actual expenses exceed the 4% allowable annual trust administration fee limitation?
YES NO (If NO, please explain.)
10. Have all funds collected been deposited into trust within thirty (30) days?
YES NO (If NO, please explain.)
11. Where any funds escheated to the State as unclaimed property?
YES NO (If NO, please explain.)
2
2021
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12. List all trustees and include each individual's residence or business address and telephone
numbers ( not the funeral establishment address and telephone number) . Identify any and all
relationships with individual trustees who are designated as NON-FIRM MEMBERS, including
business and personal relationships.
NAME
ADDRESS
PHONE
a.
_______________________
_______________________________
(____ )____________
Firm Member or Non-Firm Member
b. _______________________ _______________________________
(____ )____________
(Non-Firm Member
c. _______________________ _______________________________
(____ )____________
(Non-Firm Member
d. _______________________ _______________________________
(____ )____________
(Non-Firm Member
e.
_______________________
_______________________________
(____ )____________
(Non-Firm Member
13. How are the trustees selected?
a) By the licensee
b) By the depositor
c) Other ( Please explain ) ___________________________________________________
14. Where, in California, are the books and records of the trust funds are available for inspection or
audit by the Cemetery and Funeral Bureau?
Name of Custodian:
____________________________________________________________________________________
Name of Entity or Location: _______________________________________________________________
Address: ________________________________________ City ______________________ ZIP________
15. Who prepared this report?
Name: ________________________________________________ Telephone: (____)_______________
Address: ________________________________________ City ______________________ ZIP________
16. Who is the authorized contact person to whom questions regarding the contents of this report
should be directed.
Name: __________________________________________________ Telephone: ____)_____________
3
2021
- -
- -
- -
- -
- -
SUMMARY OF TRUST TRANSACTIONS
INCOME/
CORPUS
EXPENSE
Beginning Balance
ADD:
Corpus Received this Period
+
+
Income Earned this Period
+
+
SUBTRACT:
-
-
-
-
- -
Funds From Corpus Applied to:
Serviced Accounts
Canceled Accounts
Escheated Accounts
Funds From Income Applied to:
Serviced Accounts
Canceled Accounts
Escheated Accounts
Annual Administration Fees
Revocation Fees
ENDING BALANCES:
= = =
ENDING BALANCE BASED UPON 12/31/21 MARKET VALUATION
=
Total Number of Trustors at the Beginning of the Year =_______________
ADD: New Trustors +_______________
SUBTRACT: Serviced Accounts
-_______________
Canceled Accounts -_______________
Total Number of Trustors at the End of the Year =_______________
4
2021
____________________
____________________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
ADMINISTRATION FEE SUMMARY
INVESTMENT FEES
FILING FEES
ATTORNEY FEES
BOOKKEEPING FEES
AUDITING FEES
ADMINISTRATIVE FEES
TRUSTEE FEES
……………………………………………………….
……………………………………………………….
……………………………………………………….
……………………………………………………….
……………………………………………………….
……………………………………………………….
……………………………………………………….
……………………………………………………….
……………………………………………………….
TOTAL ADMINISTRATION EXPENSES INCURRED THIS PERIOD .……..
TOTAL ADMINISTRATION FEES RECOVERED THIS PERIOD …………..
EXCESS AMOUNT WITHDRAWN OR
<UNRECOVERED EXPENSES ACCRUED>…………………………………..
AMOUNT
NOTE:
The annual trust administration fee may not exceed 4% of the year-end balance of corpus
plus prior years' accumulated income, and may only be recovered from the income
received during the 2021 reporting period (16 CCR § 1265).
5
2021
TRUST FUND INVESTMENTS
A. Individual Passbooks (List by Financial Institution):
N
O. AVERAGE
FINANCIAL INSTITUTION & LOCATION OF ACCTS INT. RATE AMOUNT
_________________________________ ___________ ___________ ___________
_________________________________ ___________ ___________ ___________
_________________________________ ___________ ___________ ___________
_________________________________ ___________ ___________ ___________
_________________________________ ___________ ___________ ___________
A1 Total Income Earned this Period
___________
A2 Total Ending Corpus
___________
B. Commingled Checking and/or Savings Accounts (List by Financial Institution):
A
CCOUNT
ANNUAL
FINANCIAL INSTITUTION & LOCATION NUMBER AMOUNT
RETURN
_________________________________ ___________ ___________ ___________
_________________________________ ___________ ___________ ___________
_________________________________ ___________ ___________ ___________
_________________________________ ___________ ___________ ___________
_________________________________ ___________ ___________ ___________
B1 Total Income Earned this Period
____________
B2 Total Ending Corpus Listed this Period ____________
C. C
ommingled Investments (Bonds, Trust Deeds, Guaranteed Securities, etc.
):
Attach a schedule of assets showing the ORIGINAL COST and MARKET VALUE as of 12/31/21
or fiscal year end. Provide an income statement that includes realized gains and losses.
6
2021
VERIFICATIONS
(BOTH VERIFICATIONS ARE REQUIRED, EXCEPT AS NOTED IN THE INSTRUCTIONS
A. OWNER, PARTNERS, OR CORPORATE OFFICERS:
I/We hereby certify or declare under penalty of perjury, under the laws of the State of California, that, to the best
of my/our knowledge and belief, the foregoing report, including all attachments thereto, is complete, true and
correct.
1. Signature:________________________________________
Print Name:_______________________________________
2. Signature:________________________________________
Print Name:_______________________________________
Date: ____________________
Title: ____________________
Date: ____________________
Title: ____________________
Name of the Funeral Establishment:_______________________________________________
License Number: FD-__________
(BOTH VERIFICATIONS ARE REQUIRED, (B EXCEPT AS NOTED IN THE INSTRUCTIONS)
B. TRUSTEES:
I/We hereby certify or declare under penalty of perjury, under the laws of the State of California, that, to the best
of my/our knowledge and belief, the foregoing report, including all attachments thereto, is complete, true and
correct.
1. Signature:________________________________________
Print Name:_______________________________________
2. Signature:________________________________________
Print Name:_______________________________________
Date: ____________________
Title: ____________________
Date: ____________________
Title: ____________________
7
2021
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INSTRUCTIONS
These instructions may be detached and disposed of or retained after completion of the report.)
Do not return the instructions with the completed report.
PAGE 1
Check whether this is a current or final report.
If the report covers a period other than a calendar year, please indicate in the space provided what period is
covered.
PAGES 2–3
Answer all questions and provide all required information. Provide explanations as required and/or necessary.
ITEM 3 Attach a copy of the current trust agreement to the report if the trust is active. The trust will be
considered active if corpus payments are being received and/or new trustors are being added.
ITEM 11
Indicate if any preneed funds have been escheated to the State Controller’s Office as unclaimed
property
ITEM 12
The “trustee” must be either a bank or trust company authorized to act as a trustee in California;
or not less than three (3) individuals. Only one of the individual trustees may be an employee,
partner, officer, owner, director or agent of the funeral director. If friends and/or family of the
trustor/depositor are appointed trustees on individual passbook-type accounts, please indicate
that fact in this section.
List all trustees and their individual addresses and telephone numbers. Do not use the funeral
director’s address and telephone number for the non-firm member trustees.
A change in trustees in required to be reported within thirty (30) days after the effective date of
change on a Notification of Change form accompanied by the required $50.00 fee.
ITEM 14
Indicate who is responsible for maintaining the trust books and records in California and where
those records are maintained. If they are maintained at the funeral establishment, you need only
enter the words “on site” on the line asking for the name of the entity or location. If the books
and records are maintained at a location other than the funeral establishment, enter the
appropriate information.
ITEM 15
Indicate who prepared the report and how that person may be contacted.
ITEM 16
Indicate the name and telephone number of the contact person who is authorized to answer
questions regarding the report.
PAGE 4
The beginning balances should match the prior year’s ending balances. If these figures do not match, attach a
detailed explanation with supporting documentation.
“Income Earned this Period.” Is the amount of gross income or earnings derived from all trust investments
listed on Page 6.
“Funds From income Applied to: Canceled Accounts,” is the total amount of income, both accumulated and
current, refunded to the trustor upon revocation.
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2021
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“Funds From Income Applied to: Annual Trust Administration Fees,” is the total amount of current year’s
income withdrawn for the annual trust administration fee as detailed on Page 5.
“Funds From Income Applied to: Revocation Fees,” is the total amount of income, both accumulated and
current, retained as a revocation fee upon cancellation of an individual trustor account.
“Funds From Income Applied to: Escheated Accounts,” is the total amount of income, both accumulated and
current, escheated to the State Controller’s Office as unclaimed property.
PAGE 5
Detail all actual expenses attributable to the administration of the trust and enter the total as “Total
Administrative Expenses Incurred This Period.”
Enter the total amount withdrawn from the current year’s income for recovery of the annual administration fee
as “Total Administration Fees Recovered This Period.”
The total annual trust administration fee withdrawal may not exceed 4% of the year-end balance of
corpus plus prior year’s accumulated income, and may only be recovered from current year’s
income.
To calculate the total allowable withdrawal add the total beginning balance the prior year’s ending
balance from Page 4 to the corpus received this period, also from Page 4, and multiply the result by .04.
S
ubtract the “Total Administration Fee Recovered” from the “Total Administration Expenses Incurred” and
enter the difference as accrued unrecovered expenses or as an excess withdrawal where the allowable total
withdrawal exceeds actual expenses incurred .
PAGE 6
Provide detail of trust investment as indicated.
PAGE 7
ITEM A Verification must be completed for all reports, except combined reports filed pursuant to 16 CCR §
1269 f.
This verification shall be completed and signed by the owner, the partners or, in the case of a
corporation, two ( 2) officers thereof, including the president or vice-president and one other officer
of the corporation.
ITEM B Verification must be completed for all reports, including combined reports filed pursuant to 16 CCR
§ 1269 f, except as provided below.
This verification shall be completed and signed by two ( 2) individual, non-firm member trustees, if
individuals act as trustee; or by an authorized representative of the institutional trustee if a bank or
trust company acts as trustee.
In cases where individual passbook-type accounts are used, and the depositor and /or family or
friends of the depositor act as trustees, along with one member for the firm, Verification B is not
required.
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2021
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In cases where trust funds have been commingled for purposes of investment, this report shall be
prepared by a Certified Public Account or a Public Accountant, currently licensed in the State of
California. An independent audit report certifying compliance with the provisions of Article 9,
Chapter 12, Division 3 of the Business and Professions Code and Title 16, Chapter 12, Article 8 of
the California Code of Regulations must accompany this report. In addition, any findings of
noncompliance with existing law regarding preneed trust funds must be identified by the
auditor in a separate report for review and action by the Bureau. Audits and reports of
noncompliance shall be filed simultaneously Business and Professions Code § 7737.3 and
California Code of Regulations § 1269 d.
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2021
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CALl~ORNIA
o
c:
a
DEPARTMENT
OF
CONSUMER
AFFAIRS
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
CEMETERY AND FUNERAL BUREAU
1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834
P 916.574.7870 F 916.928.7988 www.cfb.ca.gov
NOTICE ON COLLECTION OF PERSONAL INFORMATION
Collection and Use of Personal Information
The Cemetery and Funeral Bureau (Bureau ) of the Department of Consumer Affairs
collects the personal information requested on this form in accordance with Business and
Professions Code sections 30, 144, 7600 et. seq., and the Information Practices Act. The
Bureau uses this information principally to identify and evaluate applicants for licensure,
issue and renew licenses, and enforce licensing and reporting standards set by law and
regulation.
Mandatory Submission
Submission of the requested information is mandatory unless otherwise noted on the
application and/or form. The Bureau cannot consider your application for licensure or
renewal unless you provide all of the requested information.
Access to Personal Information
You may review the records maintained by the Bureau that contain your personal
information, as permitted by the Information Practices Act. See below for contact
information.
Possible Disclosure of Personal Information
We make every effort to protect the personal information you provide us. The information
you provide, however, may be disclosed in the following circumstances:
In response to a Public Records Act request Government Code Section 6250 and
following ), as allowed by the Information Practices Act (Civil Code Section 1798 and
following ;
To another government agency as required by State or Federal law; or,
In response to a court or administrative order, a subpoena, or a search warrant.
Contact Information
For questions about this notice or access to your records, you may contact the Custodian
of Records, Cemetery and Funeral Bureau at 1625 North Market Boulevard, Suite S-208,
Sacramento, CA 95834, by phone at (916 ) 574-7870, or by e-mail at
emailcfb@dca.ca.gov. For questions about the Department’s Privacy Policy, you may
contact the Department of Consumer Affairs at 1625 North Market Boulevard,
Sacramento, CA 95834, by phone at (800 ) 952-5210, or by e-mail at dca@dca.ca.gov.
11
2021
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a o 2021 PRENEED FUNERAL TRUST FUND REPORT (California)

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