Name of Legal Owner E-mail Address Phone
Address City State Zip
Common Name of Cemetery County
Address City State
KS
Zip
1 / 1
K.S.A. 17-1312a; K.S.A. 17-1312f
Rev. 6/25/15 tc
a. State of incorporation
(if incorporated)
b. Date of establishment c. Date granted authority in Kansas
(if incorporated outside of Kansas)
d. Has the cemetery operated continuously since establishment? o Yes o No
e. Is the cemetery a municipality or otherwise empowered to issue bonds or levy taxes? o Yes o No
f. Does the cemetery constitute an established church and convey lots only to members and/or their relatives?
o Yes o No
g. Check one: The legal owner is a:
o cemetery organized as a for-prot corporation
o cemetery organized as a not-for-prot corporation
o cemetery organized for religious puposes
o cemetery, not a corporation
o other (provide explanation in box on right):
h. Amount currently in permanent
maintenance trust fund
$
I do hereby certify under penalty of perjury and pursuant to the laws of the state of Kansas that the information contained in
this report and supplied in any attachments thereto is true and correct.
Printed Name of Signer Title
Signature of Owner or Officer
X
Month Day Year
ka nsas secretary of state
Cemetery Registration
Kansas Secretary of State, Audit Manager:
Memorial Hall, 1st Floor
120 S.W. 10th Avenue
Topeka, KS 66612-1594
(785) 296-4564
audit@sos.ks.gov
www.sos.ks.gov
Directions: This form must be completed in full (typewritten or printed in ink) and signed. If additional space is needed in
answering any questions, please attach the information to this form as an Exhibit.
Form
CER
Please review to ensure completion.
Please complete the form, print, sign and mail to the Kansas Secretary of State. Selecting 'Print' will print the
form and 'Reset' will clear the entire form.
