Disclosure of Preneed Funeral Agreement
The funeral establishment, Chapman Funeral Home,
(funeral establishment name)
license number FD________, DOES ____, DOES NOT ____ (check one) have a preneed arrangement, as
defined below, made by or on behalf of ____________________________________________________.
(name of decedent)
If the funeral establishment does have a preneed agreement, complete the following:
In compliance with Business and Professions Code Section 7745, the funeral establishment has
presented to the person named below a copy of any preneed agreement which has been signed and
paid for in full, or in part by, or on behalf of the deceased and is in the possession of the funeral
establishment.
____________________________________________ ______________________________
Signature of funeral establishment representative Date
“Preneed arrangement,” "preneed agreement” or “preneed” is written instruction regarding goods or services
or both goods and services for final disposition of human remains when the goods or services are not provided
until the time of death, and may be either unfunded or paid for in advance of need.
Funeral Establishment’s Responsibility – Business and Professions Code Section 7745 requires a funeral
establishment to present to the survivor of the decedent or the responsible party a copy of any preneed
agreement in its possession which has been signed and paid for in full, or in part by, or on behalf of the
deceased. Business and Professions Code Section 7685.6 requires a copy of any preneed arrangements to
be disclosed prior to drafting any contract for funeral goods or services. The funeral establishment may
present the copy in person, by certified mail, or by facsimile transmission, as agreed upon by the person with
the right to control disposition. A funeral establishment that knowingly fails to present a preneed agreement as
required is liable for a civil fine equal to three times the cost of the preneed agreement, or one thousand dollars
($1,000), whichever is greater.
You may contact the Cemetery and Funeral Bureau for more information on funeral, cemetery or cremation
matters or to file a complaint against a licensee:
Cemetery and Funeral Bureau
1625 North Market Blvd., Suite S-208
Sacramento, CA 95834
916-574-7870
____________________________________________ ______________________________
Signature of the survivor or responsible party Date
____________________________________________
Print name of the survivor or responsible party
____________________________________________ ______________________________
Signature of funeral establishment representative Date
____________________________________________ ______________________________
Print name of funeral establishment representative Title
The funeral establishment must:
• Give a copy of the completed statement to the survivor or responsible party.
• Retain the original or a copy of the completed disclosure statement on file for not less than one (1) year
after the preneed account has been audited by the Bureau or seven (7) years from the date the
disclosure statement was made, whichever comes first.
21F1 (10/03)
