Fillable Application and Information Sheet for Certicate of Authority (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Application and Information Sheet for Certicate of Authority (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce 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
Application and Information Sheet for Certicate of Authority
In accordance with N.J.S.A. 45:27-7 and N.J.A.C. 13:44J-13.1
Name of Cemetery: ___________________________________________________________________________________
Address:
___________________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
Mailing Address (If different than above.):
__________________________________________________________________________________________________
Street or P.O. Box City State ZIP code County
_________________________________________________________
Contact Person: ___________________________________________________
Telephone number (include area code)
Organized Under
Special Act N.J.S.A. Title 8 or 8A N.J.S.A. Title 16 (Religious Corporation)
Cemetery Act of 1851 N.J.S.A. Title 14 Unincorporated
Cemetery Act of 1875 N.J.S.A. Title 15 or 15A N.J.S.A. Chapter 45
Date Organized: _______________________________ Date of Incoporation: ____________________________________
Type of Cemetery
Lot Owners Association Owned by Shareholder Non-Prot Prot
Other (explain): __________________________________________________________________________________
______________________________________________________________________________________________
Religious: ______________________________________________________________________________________
Name and Address of Church or Synagogue as Owner of Cemetery
Do you inter persons other than members of your religious faith or families of such members? Yes No
Total Acreage: __________________ Acres Developed: _______________ Acres Sold: ____________________
Is there a Public Mausoleum? Yes No Is there a Crematory? Yes No
Fiscal Year-Ends - _____________________________________________________________________________
Date and Time of Annual Lot Owner’s Meeting - ____________________________________________________
Name and Address of Custodial Institution Maintaining Maintenance and Preservation Fund:
____________________________________________________________________________________________
Book Value of M&P Fund: ______________________________________________________________________
Market Value of M&P Fund: _____________________________________________________________________
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
____________________________________________________________________________________________
Name Street Address City State ZIP code
____________________________________________________________________________________________
Name Street Address City State ZIP code
____________________________________________________________________________________________
Name Street Address City State ZIP code
Name and Address 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
In accordance with N.J.A.C. 13:44J-13.1, please submit the following along with this application:
1. Application fee of $500.00 (see N.J.A.C. 13:44J-3.1 (a) 1iv(1)) made payable to the State of New Jersey.
2. Copy of Articles of Incorporation and/or Charter and the By Laws.
3. Cemetery’s Rules and Regulations.
4. Cemetery’s price list for interment space and services.
5. Map of cemetery.
6. Copy of the statement from a nancial institution listing the assets of the M&P Fund signed by a Trust
Ofcer.
Above items must be mailed to: New Jersey Cemetery Board
P.O. Box 45036
Newark, New Jersey 07101
AffidAvit
State of_______________________
County of _____________________
I __________________________________________________ of full age, being duly sworn according to law,
upon this oath, depose and say that:
1. I have reviewed and understand the provisions of N.J.S.A. 45:27 et seq. and N.J.A.C. 13:44J and other
applicable regulations promulgated by the New Jersey Department of Health and the Department
of Environmental Protection.
2. I reside at __________________________________________________________________________ .
3. I am the _________________________________ of ________________________________________ .
Title Name of Cemetery
The applicant named in this application and the statements contained herein are true to the best of my
knowledge and belief.
.
Sworn & Subscribed before me
this _______ day of ______, _________
_________________________________
Signature of Notary Public
_________________________________
Date commission expires
___________________________________
Signature of Cemetery Ofcial
Afx Seal Here
Corporate Seal
Month Year
} ss.
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Application and Information Sheet for Certicate of Authority (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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