Form 440-4016 "Endowment Care Cemetery Annual Report" - Oregon

What Is Form 440-4016?

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 September 1, 2015;
  • 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 440-4016 by clicking the link below or browse more documents and templates provided by the Oregon Department of Consumer and Business Services.

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Download Form 440-4016 "Endowment Care Cemetery Annual Report" - Oregon

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Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Rm. 410, Salem, OR 97301-3881
Mailing address: P.O. Box 14480, Salem, OR 97309-0405
503-378-4140  Fax: 503-947-7862
http://dfcs.oregon.gov
ENDOWMENT CARE CEMETERIES ANNUAL REPORT
INSTRUCTIONS FOR ANNUAL REPORT
The following instructions pertain to the annual report to be filed with the director of the Department of
Consumer and Business Services, as required by ORS 97.810(3).
The information requested must show accurately the financial condition of the trust on the date of the statement;
it enables the director of DCBS to fulfill his or her responsibility under ORS 97.810(3).
ORS 97.810(5) provides authority to require additional reports of the condition and assets of the endowment
fund, should the director require them.
ENDOWMENT CARE FUND ANNUAL REPORT
A standard annual report form is available from the Department of Consumer and Business Services. Use of the
standard form is not mandatory, but the information requested on the standard form must be included in your
report. The Department of Consumer and Business Services form requests the following information:
Page 1 — Include depository and a list of cemetery officers
Page 2 — Owner verification of report accuracy and compliance with legal requirements
Page 3 — Balance sheet
Page 4 — Endowment principal and income transactions
Page 5 — Summary of cash and installment sales
Endowment care fund annual reports are public records available for inspection by the public.
DUE DATE
The endowment care annual report is required by ORS 97.810(3) to be filed within 75 days following the
end of the fiscal year covered by the report.
The annual reports should be filed with:
Fiscal Services Section
Department of Consumer and Business Services
P.O. Box 14610
440-4016 (9/15/COM)
Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Rm. 410, Salem, OR 97301-3881
Mailing address: P.O. Box 14480, Salem, OR 97309-0405
503-378-4140  Fax: 503-947-7862
http://dfcs.oregon.gov
ENDOWMENT CARE CEMETERIES ANNUAL REPORT
INSTRUCTIONS FOR ANNUAL REPORT
The following instructions pertain to the annual report to be filed with the director of the Department of
Consumer and Business Services, as required by ORS 97.810(3).
The information requested must show accurately the financial condition of the trust on the date of the statement;
it enables the director of DCBS to fulfill his or her responsibility under ORS 97.810(3).
ORS 97.810(5) provides authority to require additional reports of the condition and assets of the endowment
fund, should the director require them.
ENDOWMENT CARE FUND ANNUAL REPORT
A standard annual report form is available from the Department of Consumer and Business Services. Use of the
standard form is not mandatory, but the information requested on the standard form must be included in your
report. The Department of Consumer and Business Services form requests the following information:
Page 1 — Include depository and a list of cemetery officers
Page 2 — Owner verification of report accuracy and compliance with legal requirements
Page 3 — Balance sheet
Page 4 — Endowment principal and income transactions
Page 5 — Summary of cash and installment sales
Endowment care fund annual reports are public records available for inspection by the public.
DUE DATE
The endowment care annual report is required by ORS 97.810(3) to be filed within 75 days following the
end of the fiscal year covered by the report.
The annual reports should be filed with:
Fiscal Services Section
Department of Consumer and Business Services
P.O. Box 14610
440-4016 (9/15/COM)
FILING FEE
ORS 97.810(6)(a)(b) requires a fee to be paid by each endowment care cemetery at the time of filing of the
statement. Annual fees shall be paid to the director of the Department of Consumer and Business Services as
follows:
Up to 100 interments per year — $40
More than 100 interments per year — $100
TRUST OR CUSTODIAL AGREEMENT
A current copy of the trust or custodial agreements required by Oregon Revised Statute 97.820(3) shall be filed
with the Department of Consumer and Business Services.
INTERPRETATION OF INSTRUCTIONS
If the cemetery authority has questions concerning the interpretation or application of these instructions, direct
them to the Department of Consumer and Business Services, Division of Financial Regulation: Phone (503)
378-4140  Fax (503) 947-7862
440-4016 (9/15/COM)
Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Rm. 410, Salem, OR 97301-3881
Mailing address: P.O. Box 14480, Salem, OR 97309-0405
503-378-4140  Fax: 503-947-7862
http://dfcs.oregon.gov
ENDOWMENT CARE CEMETERY ANNUAL REPORT
As required by ORS 97.810(3)
Cemetery Board License no:
EC# (DFCS use):
Fiscal year covered by this report:
through
Name of cemetery:
Cemetery address:
City/State/ZIP:
Corporate or business name:
Mailing address (if different):
City/State/ZIP:
Officers
Name:
Title:
Name:
Title:
Name:
Title:
Name:
Title:
Name:
Title:
Trustee or custodian (ORS 97.820(3)) - Authorized Financial Institution
Name:
Mailing address:
City/State/ZIP:
Send report with payment to:
FISCAL USE ONLY: 61260/1007
DCBS Fiscal Services Section
P.O. Box14610
Salem, OR 97309-0445
Secure fax line for credit card payments:
503-947-2333
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440-4016 (9/15/COM)
Name of cemetery:
Is the entire cemetery under endowed care?
Yes
No
If no, how much is under endowed care?
Is this location also selling trust funded prearrangement or preconstruction plans?
Yes
No
DUE DATE
This report is required by statute to be filed with the director of the Department of Consumer and Business
Services within 75 days following the close of the fiscal year covered by the report.
FILING FEE (ORS 97.810(6)(a)(b))
• Up to 100 interments per year — $40
• More than 100 interments per year — $100
Number of interments this year:
Filing fee enclosed: $
VERIFICATION OF OWNER OR OFFICER
I, (name)
being the (title)
of the (name of cemetery)
hereby affirm that I have personal knowledge of the contents of the financial and statistical statements included in
this report, that the information contained herein is correct and in agreement with the financial and other records of
the cemetery, and that endowed-care monies have been collected, deposited, and expended in accordance with
applicable legal requirements.
Date:
Signature:
Phone number: (
)
Fax number: (
)
Email address:
Please submit copies of the following with your annual report:
 Cemetery board license
 Sales contract
 Certificate of ownership or deeds
 Price list (if applicable)
New trust agreement (if changes been made)
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440-4016 (9/15/COM)
Please provide supporting documentation for this page.
Name of cemetery:
Endowment Care Fund Statement of Financial Condition
Date:
Assets
Cash on hand: ..........................................................
$
Cash in banks
Checking accounts: ............................................
$
Savings accounts: ...............................................
$
Time deposits: ....................................................
$
Investments: ............................................................
$
Other assets: ............................................................
$
Total assets: .............................................................
$
$
Liabilities and fund balance
Liabilities: ...............................................................
$
Trust balances
Principal (nonexpendable, Page 4) .....................
$
Income (expendable, Page 4) .............................
$
Total liabilities and fund balance: ...........................
$
$
(Total assets and Total liabilitiesand fund balance amounts must match the balance amounts on page 4)
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