Fillable Annual Report Of Maintenance And Preservation Fund And Other Funds (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Annual Report Of Maintenance And Preservation Fund And Other Funds (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Office of the Attorney General
Division of Consumer Affairs
New Jersey Cemetery Board
124 Halsey Street, 6th Floor, P.O. Box 45036
Newark, New Jersey 07101
(973) 504-6553
Annual Report of Maintenance and Preservation Fund and Other Funds
Fiscal Year Ended: ________________________
Month Day Year
1. ___________________________________________________________ _________________________________
Name of Cemetery Certicate of Authority Number
2. _____________________________________________________________________________________________________
Location - Street Address City State ZIP code
3. _____________________________________________________________________________________________________
Mailing - Street Address City State ZIP code
4. ___________________________________________________________ _________________________________
Name - Contact person for Cemetery Telephone number (include area code)
5. Status: For Prot Non-Prot
6. Are there outstanding Certicates of Interest/Indebetdness/Stock? Yes No
7. How many cremations were performed by your Crematory? _________________
8. Name(s) and address(es) of custodial bank(s) for Maintenance and Preservation (M&P) and other trust funds:
a. ___________________________________________________________________________________________________
Name of Bank Street Address City State ZIP code
b. ___________________________________________________________________________________________________
Name of Bank Street Address City State ZIP code
c. ___________________________________________________________________________________________________
Name of Bank Street Address City State ZIP code
d. ___________________________________________________________________________________________________
Name of Bank Street Address City State ZIP code
9. Name and address of individuals who control/direct M&P Fund Investments:
_____________________________________________________________________________________________________
Name Street Address City State ZIP code
_____________________________________________________________________________________________________
Name Street Address City State ZIP code
- 1 -
10. Book value of M&P fund at beginning of current scal year: $
11. a) Total receipts collected from lot and grave sales - enter in A, $ _________________ $ ___________________
15% of A - enter in B
b) number of bulk grave sales x current gross price of comparable $ _________________ $ ___________________
graves - enter in A, 15% of A - enter in B
12. Amount of lot and grave resales - enter in A, 15% of A less $ _________________ $ ___________________
M&P previously paid - enter in B
13. a) Total receipts collected from crypt and niche sales - enter in A, $ _________________ $ ___________________
10% of A - enter in B
b) number of bulk crypt and niche sales x current gross sales price $ _________________ $ ___________________
of comparable crypts or graves - enter in A, 10% of A - enter in B
14. Amount of crypt and niche resales - enter in A, 15% of A less $ _________________ $ ___________________
M&P previously paid - enter in B
15. Enter total number of interments in Column A: # _________________
a) Total receipts collected for interment fees over $660.00 each, $ _________________ $ ___________________
enter in A; 3% of A - enter in B
b) Enter number of interments for interment fees of less than # _________________ $ ___________________
$660.00 each in A; A x $20.00 - enter in B
16. a) Total receipts collected for each foundation $200.00 and over - $ _________________ $ ___________________
enter in A, 10% of A - enter in B
b) Total number of foundations under $200.00 each - enter in A, # _________________ $ ___________________
A x $20.00 - enter in B
17. TOTAL DEPOSITED: $ ___________________
18. Monies deposited to put old graves under M&P ___________________ $ ____________________
19. Reversal of deposits in transit for - ___________________________ ___________________ + $ ____________________
Date of prior scal year end
20. Deposits in transit for - ___________________________ ___________________ ( $ ___________________ )
Date of current scal year end
21. Capital Gain from Sale of Investments ___________________ + $ ____________________
22. Loss from Sale of Investments ___________________ ( $ ___________________ )
23. (See Instructions)_____________________________________________________________ ____________________
24. (See Instructions)_____________________________________________________________ ____________________
25. Book Value of M&P Fund at end of current scal year $
26. Total income earned by M&P for current year (interest and dividends) __________________ $ ___________________
a. Amount to be used for general operating expenses ___________________ $ ___________________
b. Amount retained in M&P Fund corpus ___________________ $ ___________________
A - Amount
B - Amount Deposited
into M&P Fund
- 2 -
27. Fees due New Jersey Cemtery Board:
$ 75.00 Filing Fee
$ Interment (line 15 Column A - subtract 25 and multiply balance by $4.00)
$ Cremations Performed by Cemeteries Operating Crematories
$ Total to be submitted with this report
28. Annual Report of Maintenance and Preservation Trust Funds
__________________________________________________ $ _________________ $ ___________________
Trust Fund Name
__________________________________________________
$ _________________ $ ___________________
Name of Custodial Institution Account Number
__________________________________________________ $ _________________ $ ___________________
Trust Fund Name
__________________________________________________
$ _________________ $ ___________________
Name of Custodial Institution Account Number
__________________________________________________ $ _________________ $ ___________________
Trust Fund Name
__________________________________________________
$ _________________ $ ___________________
Name of Custodial Institution Account Number
__________________________________________________ $ _________________ $ ___________________
Trust Fund Name
__________________________________________________
$ _________________ $ ___________________
Name of Custodial Institution Account Number
__________________________________________________ $ _________________ $ ___________________
Trust Fund Name
__________________________________________________
$ _________________ $ ___________________
Name of Custodial Institution Account Number
Total Book Value of M&P Fund - Line 25
$ _________________ $ ___________________
29. Annual Report of Other Trust Funds
__________________________________________________ $ _________________ $ ___________________
Trust Fund Name
__________________________________________________
$ _________________ $ ___________________
Name of Custodial Institution Account Number
_____________________________________________________________________________________
Purpose of Trust
__________________________________________________ $ _________________ $ ___________________
Trust Fund Name
__________________________________________________
$ _________________ $ ___________________
Name of Custodial Institution Account Number
_____________________________________________________________________________________
Purpose of Trust
__________________________________________________ $ _________________ $ ___________________
Trust Fund Name
__________________________________________________
$ _________________ $ ___________________
Name of Custodial Institution Account Number
_____________________________________________________________________________________
Purpose of Trust
Total: $ _________________ $ ___________________
Book Value/Tax Cost
Market Value
Book Value/Tax Cost
Market Value
Current Year End Value
- 3 -
30. Names and Addresses of Ofcers:
_____________________________________________________________________________________________________
President - Name Street Address City State ZIP code
_____________________________________________________________________________________________________
Vice-President - Name Street Address City State ZIP code
_____________________________________________________________________________________________________
Secretary - Name Street Address City State ZIP code
_____________________________________________________________________________________________________
Treasurer - Name Street Address City State ZIP code
31. Names and Addresses of Trustees or Directors:
_____________________________________________________________________________________________________
Name Street Address City State ZIP code
_____________________________________________________________________________________________________
Name Street Address City State ZIP code
_____________________________________________________________________________________________________
Name Street Address City State ZIP code
_____________________________________________________________________________________________________
Name Street Address City State ZIP code
_____________________________________________________________________________________________________
Name Street Address City State ZIP code
_____________________________________________________________________________________________________
Name Street Address City State ZIP code
_____________________________________________________________________________________________________
Name Street Address City State ZIP code
_____________________________________________________________________________________________________
Name Street Address City State ZIP code
_____________________________________________________________________________________________________
Name Street Address City State ZIP code
AffidAvit
State of New Jersey
County of _____________________ }ss
I, ___________________________________________________________________________________________ , of
Name Title
_____________________________________________________________ attest to the fact that I have reviewed this
Name of Cemetery
report and the statement(s) of account(s) from the bank(s) having custody of the Maintenance and Preservation Fund
and the lists of investments. The information contained in this report and on the attached list of investments is a true
and correct statement, to the best of my knowledge, as of the end of the scal year of ________________________.
Month and Year
Sworn & Subscribed before me
this _______ day of ______, _________
_________________________________
Signature of Notary Public
_________________________________
Date commission expires
Month Year
___________________________________
Signature of Cemetery Ofcial
Afx Seal Here
Corporate Seal
- 4 -
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Annual Report Of Maintenance And Preservation Fund And Other Funds (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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