Form 440-4013 "Funeral and Cemetery Consumer Protection Trust Fund Certified Provider Contract Sales Annual Report" - Oregon

What Is Form 440-4013?

This is a legal form that was released by the Oregon Department of Consumer and Business Services - a government authority operating within Oregon. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2017;
  • The latest edition provided by the Oregon Department of Consumer and Business Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 440-4013 by clicking the link below or browse more documents and templates provided by the Oregon Department of Consumer and Business Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form 440-4013 "Funeral and Cemetery Consumer Protection Trust Fund Certified Provider Contract Sales Annual Report" - Oregon

Download PDF

Fill PDF online

Rate (4.4 / 5) 8 votes
Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Rm. 410, Salem, Oregon 97301
Mailing address: P.O. Box 14480, Salem, OR 97309-0405
503-378-4140  Fax: 503-947-7862
http://dfr.oregon.gov
FUNERAL AND CEMETERY CONSUMER PROTECTION TRUST FUND
CERTIFIED PROVIDER CONTRACT SALES ANNUAL REPORT
Due date for annual report: Jan. 31
Purpose of the fund: The special income earning fund is held by the State Treasury, separate from the
General Fund. The purpose of the fund is to provide restitution to purchasers who have suffered
pecuniary loss arising out of prearrangement sales contracts or preconstruction sales contracts. The
DCBS director administers the fund and adopts rules governing restitution payments. Payments for
restitution shall be made only when the director determines that the obligation is not collectible from the
certified provider and orders payments.
Purpose of the report: Every certified provider per Oregon Revised Statute 97.923(2) must file an
annual report and pay a $5 fee for each contract sale. The director of the Department of Consumer and
Business Services is responsible for collecting the fee.
Failure to file report or pay fee: An annual report must be submitted even if no contracts are sold. The
director may send a notice to the Oregon Mortuary and Cemetery Board, limit certification, suspend
certification, revoke certification, assess a civil penalty, or take any other disciplinary proceedings for
failure to file a report or pay a fee.
Governing statutes and rules: Oregon Revised Statute 97.945
INCOMPLETE OR INACCURATE REPORTS WILL BE RETURNED TO
THE CERTIFIED PROVIDER FOR COMPLETION OR CORRECTIONS.
Questions? 503-378-4140
More information:
www.dfr.oregon.gov
Page 1
440-4013 (6/17/COM)
Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Rm. 410, Salem, Oregon 97301
Mailing address: P.O. Box 14480, Salem, OR 97309-0405
503-378-4140  Fax: 503-947-7862
http://dfr.oregon.gov
FUNERAL AND CEMETERY CONSUMER PROTECTION TRUST FUND
CERTIFIED PROVIDER CONTRACT SALES ANNUAL REPORT
Due date for annual report: Jan. 31
Purpose of the fund: The special income earning fund is held by the State Treasury, separate from the
General Fund. The purpose of the fund is to provide restitution to purchasers who have suffered
pecuniary loss arising out of prearrangement sales contracts or preconstruction sales contracts. The
DCBS director administers the fund and adopts rules governing restitution payments. Payments for
restitution shall be made only when the director determines that the obligation is not collectible from the
certified provider and orders payments.
Purpose of the report: Every certified provider per Oregon Revised Statute 97.923(2) must file an
annual report and pay a $5 fee for each contract sale. The director of the Department of Consumer and
Business Services is responsible for collecting the fee.
Failure to file report or pay fee: An annual report must be submitted even if no contracts are sold. The
director may send a notice to the Oregon Mortuary and Cemetery Board, limit certification, suspend
certification, revoke certification, assess a civil penalty, or take any other disciplinary proceedings for
failure to file a report or pay a fee.
Governing statutes and rules: Oregon Revised Statute 97.945
INCOMPLETE OR INACCURATE REPORTS WILL BE RETURNED TO
THE CERTIFIED PROVIDER FOR COMPLETION OR CORRECTIONS.
Questions? 503-378-4140
More information:
www.dfr.oregon.gov
Page 1
440-4013 (6/17/COM)
Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Rm. 410, Salem, Oregon 97301
Mailing address: P.O. Box 14480, Salem, OR 97309-0405
503-378-4140  Fax: 503-947-7862
http://dfr.oregon.gov
FUNERAL AND CEMETERY CONSUMER PROTECTION TRUST FUND
Certified Provider Annual Contract Sale Report (ORS 97.945)
Reporting period: Jan. 1 to Dec. 31
Due date: Jan. 31
For calendar year:
Certification annual fee: Number of contracts X $5 (See Section II)
Certified provider number (one annual report per certified provider): CP-
Business name:
ABN name
:
(if applicable)
Address where business conducted
:
(P.O. Box number not acceptable)
City, state, ZIP:
Business phone number:
Business fax number:
Business e-mail:
Contact name and title:
Mailing address
:
(if different than where business conducted)
City, state, ZIP:
Instructions:
1. Complete Section I, on Page 3.
2. Calculate the total fee due in Section II, on Page 3.
3. Attach a list of the contracts sold during the reporting period or indicate no contracts sold. The list must be in
consecutive contract number order.
No contracts sold
The list must include the following information:
d. Beneficiary’s name and purchaser’s name
a. Name of depository or master trustee
b. Contract number
e. Revocable or irrevocable
c. Contract date
f. Guaranteed or nonguaranteed
Social Security numbers are not required, but if included, only show the last four numbers.
4. Provide a list of all contracts that are VOIDs during the reporting period.
Not applicable
Applicable (see enclosed list)
5. Provide an explanation for missing contract numbers or numbers used out of sequence.
Not applicable
Applicable (see enclosed explanation)
Continued on Page 3
Secure fax for credit card payments:
Make check or money order payable to Oregon
503-947-2333
Division of Financial Regulation.
If paying by credit card, applicant must sign
Mail application with payment to:
credit-card information box.
DCBS — Fiscal Services
P.O. Box 14610
Visa
MasterCard
Discover
Phone:
Salem, OR 97309-0445
Credit card number
Expiration date
Fiscal use only: 61261/1105
Name of cardholder as shown on credit card
$
Cardholder signature
Amount
Page 2
440-4013 (6/17/COM)
Section I: (Trust funded only)
A. Number of consecutively numbered prearrangement sales contracts .............................................
B. Number of consecutively numbered preconstruction sales contracts ..............................................
C. Subtract number of VOIDED prearrangement and/or preconstruction contracts ...........................
D. Total number of contracts sold (A + B – C) ....................................................................................
Section II: Funeral and Cemetery Consumer Protection Trust Fund fee (Line D x $5) .............................. $
Signature:
Title:
Type or print name:
Date:
Page 3
440-4013 (6/17/COM)
Page of 3