Fillable FD APPLICATION FOR ASSIGNMENT OF FUNERAL ESTABLISHMENT APPLICATION (California)

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FD APPLICATION FOR ASSIGNMENT OF FUNERAL ESTABLISHMENT APPLICATION (California)

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BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
CEMETERY AND FUNERAL BUREAU
1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834
P 916.574.7870 F 916.928.7988 www.cfb.ca.gov
APPLICATION FOR ASSIGNMENT OF FUNERAL ESTABLISHMENT
APPLICATION FEE $300
SECTION A: FUNERAL ESTABLISHMENT INFORMATION
Name of Funeral Establishment License Number Expiration Date
FD
New Name of Funeral Establishment (if different than above) E-mail Address (not required)
Address of Funeral Establishment
City
State
CA
Zip Code
Mailing Address of Funeral Establishment (if applicable)
City State Zip Code
Phone Number
( )
Fax Number
( )
E-mail Address (Not required)
Name of Establishment Designated as the Main Office (required only if sharing manager or
preparation and/or storage)
License Number
FD
Miles from FD listed in
Section A
Address of Main Office City State
CA
Zip Code
SECTION B: NAME OF APPLICANT (if corporation, submit a resolution delegating authority to applicant to submit the application)
Last Name First Telephone Number (if different than above)
(
)
SECTION C: NAME OF DESIGNATED FUNERAL DIRECTOR
Last Name First License Number
FDR
Expiration Date
Sharing Funeral Director (if applicable, must be under common ownership, and within 60 miles of main office)
Designated Funeral Director have also been
approved to manage the following licensed
Funeral Establishments.
FD # FD # FD # FD # FD #
SECTION D: LOCATION OF PREPARATION AND STORAGE APPOVAL TO SHARE
Storage on Site: Yes No Preparation on Site: Yes No
If yes to both, proceed to Section E
Must be within 60 miles
Sharing:
Yes No
of the main office if
sharing.
Address of Preparation and/or Storage (if different from establishment address) Sharing with the Following Establishment(s)
Storage Preparation or Both
FD #
Miles From
Main Office
Under Common Ownership:
Yes No
No, submit contractual
agreement
Street City Zip
Storage Preparation or Both
FD #
Miles From
Main Office
Under Common Ownership:
Yes No
No, submit contractual
agreement
Street City Zip
FOR BUREAU USE ONLY
Date Cashiered Amount Received ATS ID Number Receipt Number
Affidavit’s
Received
Common
Ownership
Checked
Within
60 Miles
Inspection
Notice Sent
(If applicable)
Application Approved Relate
License
Statues/Notes
Screen
New
Establishment
License Ordered
Duplicate Manager
License Ordered
(If required)
REV (07/20) Cemetery and Funeral Bureau –www.cfb.ca.gov Page 1 of 5
SECTION E: OWNERSHIP (INDIVIDUAL, PARTNERSHIP OR CORPORATION)
Effective Date of Sale FEIN Number
If owner is an INDIVIDUAL, complete the following:
Last Name First Middle Initial
ATTACH A COMPLETED CERTIFICATION AFFIDAVIT WITH THIS APPLICATION.
If owner is a PARTNERSHIP – List all general partners
(Submit a partnership agreement, attach additional pages as needed)
Last Name First Middle Initial % Owned
ATTACH A COMPLETED CERTIFICATION AFFIDAVIT FOR EACH PARTNER.
If owner is a CORPORATION, complete the following (attach a copy of the articles of incorporation)
Name of Corporation (exact name as shown on Articles of Incorporation)
Address (If different than establishment address) City State Zip
Incorporated in State of Date Incorporated
CORPORATE OFFICERS – List the top 4 Senior Officers of the Corporation
Title Last Name First Name
Middle Initial
President
Vice President
Treasurer
Secretary
ATTACH A COMPLETED CERTIFICATION AFFIDAVIT FOR EACH OFFICER.
SECTION F: FUNERAL TRUST FUNDS PRENEED REPORTING
This funeral establishment has: (check one)
1. No Preneed trust accounts.(submit a completed preneed funeral trust fund declaration of non reporting status)
2. Preneed trust accounts but they are non-reportable. (SUBMIT a completed preneed funeral trust fund declaration of non
reporting status)
3. Has reportable Preneed trust accounts.(SUBMIT a trust fund report up to the date of sale)
SECTION G: TRUSTEE’S (If applicable, only one Trustee can be an employee or officer of the funeral establishment)
Last Name First Name Middle Initial
ATTACH A COMPLETED CERTIFICATION AFFIDAVIT FOR EACH TRUSTEE.
REV (07/20) Cemetery and Funeral Bureau –www.cfb.ca.gov Page 2 of 5
SECTION H: CERTIFICATION OF ASSIGNEES (Buyers)
We/I desiring to transact the business of a Funeral Establishment within the State of California, hereby make application for the
assignment of the funeral establishment listed on page 1 of this application, pursuant to the provisions of Section 7630 of the California
Business and Professions Code.
I certify under penalty of perjury under the laws of the State of California that all statements furnished in connection with this application
are true and accurate.
Signature Print Name Title Date
Signature Print Name Title Date
Signature Print Name Title Date
SECTION I: ASSIGNORS (Sellers)
I/We, the present holders of the Funeral Establishment License Number , hereby consent to the above-referenced
assignment and relinquish all my/our right, title, and interest in the said license. It is understood that the assignor(s), pending approval of
this application, is/are responsible under the above named License Number. I/We certify under penalty of perjury that the foregoing is
true and correct.
I certify under penalty of perjury under the laws of the State of California that all statements furnished in connection with this application
are true and accurate.
Signature Print Name Title Date
Signature Print Name Title Date
Signature Print Name Title Date
SECTION J: ESTATE (For use if Assignment is from an Estate, sub
court’s interim or final disposition papers with this application.)
Signature of Executor/Trix of Estate
mit the death certificate, copies of the probate court’s testamentary letter
Print Name
s, and the probate
Date
Signature of Executor/Trix of Estate Print Name Date
SECTION K: CREMATED REMAINS CERTIFICATION
The funeral establishment identified on page one of this application has disposed of all cremated remains, which have been in my/our
custody and that at this time there are no cremated remains on the premises.
Signature of Assignee Print Name Date
Signature of Assignor Print Name Date
SECTION L: CERTIFICATION OF APPLICANT
I certify under penalty of perjury under the laws of the State of California that all statements furnished in connection with this application
are true and accurate.
Signature
Title Date
Note: The information solicited on this form is required pursuant to Business and Professions Code Section 7630. All items in this application are mandatory; none
are voluntary, unless stated. Failure to provide any of the requested information will result in the application being considered incomplete (incomplete applications
are subject to abandonment one year from the date the applicant is notified of deficiencies). All information provided will be used to determine qualification for
licensure, per the Business and Professions Code that authorizes the collection of this information. Per California Civil Code Section 1798.17 (Information Practice
Act), the Chief of the Cemetery and Funeral Bureau is responsible for maintaining information in this application. This information may be transferred to other
governmental and enforcement agencies. Individuals have the right to review the records maintained on them by the agencies, unless the records are exempt by
Section 1798.40 of the Civil Code. Requests for information may be addressed to the custodian of records: Bureau Chief, Cemetery and Funeral Bureau, 1625 North
Market Blvd., Suite S-208, Sacramento, CA 95834, (916) 574-7870.
REV (07/20) Cemetery and Funeral Bureau –www.cfb.ca.gov Page 3 of 5
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
CEMETERY AND FUNERAL BUREAU
1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834
P 916.574.7870 F 916.928.7988 www.cfb.ca.gov
CERTIFICATION AFFIDAVIT
To be completed by each Owner, Partner, Officer, and Trustee (Make additional copies as needed).
I am completing this Affidavit as a:
Sole Owner Partne Trusteer Officer
Name of Funeral Establishment, Cemetery, Crematory or Corporation this Affidavit is being submitted on behalf of
Phone Number License Number of FD, CR or COA (If applicable)
( )
e First Middle Initial Last Nam
Address City State Zip Code
Date of Birth
Social Security Number Title (If applicable)
Have you previously submitted fingerprint cards or a copy of a Request for Live Scan Service Form
to the Cemtery and Funeral Bureau?
If yes, for what license, and the approximate date.
No Yes
If no, submit a copy of your completed Request for Live Scan Service form, along with this application, verifying
that fingerprints have been scanned and all applicable fees have been paid.
Have you ever had any professional or vocational license or registration denied, suspended, revoked, placed on probation or
other disciplinary action taken by this or an y other governmental authority in this state or any other state, or any foreign
country
No Yes
If "yes," please attach an explanation that includes license type, action, and company name
(if applicable), year of action and state.
I hereby certify under penalty of perjury under the laws of the State of California to the truth and accuracy of all statements, answers and
representations made in the foregoing certification affidavit, including all supplementary statements.
Signature Date
FOR BUREAU USE ONLY
Fingerprints on File with Live Scan Results Received on
Approved by Enforcement Approval Date
Section 30 of the Business and Professions Code and Public Law 94-455 (42 U.S.C.A. 405 (c)(2)(c)) authorizes the collection of your Social Security Number (SSN). The
disclosure of your SSN is mandatory. The information will be used exclusively for tax enforcement purposes and for purposes of compliance with Section 11350.6 of the
Welfare and Institutions Code. If you fail to disclose your SSN, you will be reported to the Franchise Tax Board, which may assess a $100.00 penalty against you. Questions
regarding this requirement must be directed to the Franchise Tax Board: So. California (800) 852-7050, No. California (800) 852-5711, or Sacramento at (916) 369-0500.
REV (07/20) Cemetery and Funeral Bureau –www.cfb.ca.gov Page 4 of 5
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
CEMETERY AND FUNERAL BUREAU
1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834
P 916.574.7870 F 916.928.7988 www.cfb.ca.gov
INFORMATION AND CHECK LIST FOR
COMPLETING AN ASSIGNMENT APPLICATION
The attached application must be completed when a funeral establishments changes ownership, incorporates, adds a partner, or
when the owner dies leaving the funeral establishment as all or part of an estate.
INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR ASSIGNMENT
Section A: Funeral Establishment Information
Section B: Name of Applicant (person submitting the application, on behalf of themselves, a partnership or a corporation)
Section C: Designate a Funeral Director (if sharing the designated funeral director list all additional establishments the funeral
director has been approved to manage.)
Section D: Location of Preparation and/or Storage (state if onsite, if not, address of preparation and/or storage and if sharing
who are you sharing with (if not under common ownership, submit a contractual agreement with this application))
Section E: Ownership (state if you are filling as a Individual, a partnership or a corporation, fill out the corresponding
information (a certification affidavit must be submitted for individual owners, partners or corporate officers)
Section F: Funeral Trust Fund Preneed Reporting (check one and submitted the required form up to the date of sale)
Section G: Trustees (to be completed only if you plan to have individual trustees, a certification affidavit must be submitted for
each trustee)
Section H: Certification of Assignees (Buyers)
Section I: Certification of Assignors (Sellers)
Section J: Estate (for use if assignment if from an Estate, submit a death certificate, copies of the probate court’s testamentary
letters, and the probate courts interim or final disposition papers with this application)
Section K: Cremated Remains Certification
Section L: Certification of Applicant
CHECK LIST
A completed application with the required fees.
A copy of the articles of incorporation if a corporation (include a corporate resolution specifically authorizing the
applicant to purse the application on behalf of the corporation).
A copy of a Partnership agreement if a partnership.
Include a certification affidavit for each owner, partner, corporate officer and trustee.
If you are sharing preparation and/or storage and it is not under common ownership, submit a contractual agreement with
the establishment you are sharing with.
A completed preneed funeral trust fund declaration of non-reporting status or a trust fund report up to the date of sale.
Return the original wall license (keep the renewal to show your license is current).
Submit a copy of the sales agreement.
REV (07/20) Cemetery and Funeral Bureau –www.cfb.ca.gov Page 5 of 5
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
CEMETERY AND FUNERAL BUREAU
1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834
P 916.574.7870 F 916.928.7988 www.cfb.ca.gov
NOTICE ON COLLECTION OF PERSONAL INFORMATION
Collection and Use of Personal Information
The Cemetery and Funeral Bureau of the Department of Consumer Affairs collects the
personal information requested on this form as authorized by Business and Professions
Code Sections 30, 144, 7617.1, 7618, 7619, 7620, 7628, 7642, 7643, 7661, 7662, 7665,
7667, 9650, 9650.2, 9650.3, 9700, 9701, 9702.1, 9704, 9715, 9715.1, 9716, 9723,
9723.1, 9741, 9745, 9746, 9781, 9787.3 and the Information Practices Act. The
Cemetery and Funeral Bureau uses this information principally to identify and evaluate
applicants for licensure, issue and renew licenses, and enforce licensing standards set by
law and regulation.
Mandatory Submission
Submission of the requested information is mandatory unless otherwise noted on the
form. The Cemetery and Funeral Bureau cannot consider your application for licensure or
renewal unless you provide all of the requested information.
Access to Personal Information
You may review the records maintained by the Cemetery and Funeral Bureau that
contain your personal information, as permitted by the Information Practices Act. See
below for contact information.
Possible Disclosure of Personal Information
We make every effort to protect the personal information you provide us. The information
you provide, however, may be disclosed in the following circumstances:
In response to a Public Records Act request (Government Code Section 6250 and
following), as allowed by the Information Practices Act (Civil Code Section 1798 and
following);
To another government agency as required by State or Federal law; or,
In response to a court or administrative order, a subpoena, or a search warrant.
Contact Information
For questions about this notice or access to your records, you may contact the Custodian
of Records, Cemetery and Funeral Bureau at 1625 North Market Boulevard, Suite S-208,
Sacramento, CA 95834, by phone at (916) 574-7870, or by e-mail at
emailcfb@dca.ca.gov. For questions about the Department’s Privacy Policy, you may
contact the Department of Consumer Affairs at 1625 North Market Boulevard,
Sacramento, CA 95834, by phone at (800) 952-5210, or by e-mail at dca@dca.ca.gov.
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FD APPLICATION FOR ASSIGNMENT OF FUNERAL ESTABLISHMENT APPLICATION (California)

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Completed 8 June 2021

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