Fillable FD NOTIFICATION OF CHANGE SECTION A: ESTABLISHMENT INFORMATION (California)

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FD NOTIFICATION OF CHANGE SECTION A: ESTABLISHMENT INFORMATION (California)

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NOTIFICATION OF CHANGE
P 916.574.7870 F 916.928.7988 www.cfb.ca.gov
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
CEMETERY AND FUNERAL BUREAU
1625 N. Market Blvd., Suite S-208, Sacramento, CA 95834
Change of Managing Funeral Director $50.00 Fee
(Complete Sections A, B and F and, if applicable, Section C)
Change of, or adding Corporate Officers $50.00 Fee
(Complete Sections A, D, F and attach Affidavit(s))
Change of, or adding, Preneed Trustees $50.00 Fee
(Complete Sections A, E, F and attach Affidavit(s))
SECTION A: ESTABLISHMENT INFORMATION
Funeral Establishment Name License Number
FD
Expiration Date
Address City State
CA
Zip Code
Contact Person for this application Telephone Number
( )
Email Address (Not required)
SECTION B: CHANGE OF MANAGING FUNERAL DIRECTOR
Name of Previous Managing Funeral Director License Number
FDR
Date of Disassociation
Name of Current Managing Funeral Director License Number
FDR
Expiration Date Date of Association
Is this Funeral Director Designated
as Manager at any other Establishment? No Proceed to Section F, if Yes Complete Section C
SECTION C: APPROVAL TO SHARE MANAGING FUNERAL DIRECTOR
(If applicable, establishments must be under common ownership and within 60 miles of the main office)
Name of Establishment Designated as Main Office FD License Number Miles From FD In Section A
Address of Main Office City State
CA
Zip Code
LIST ALL ADDITIONAL FUNERAL ESTABLISHMENTS MANAGED
License Number
FD
License Number
FD
License Number
FD
License Number
FD
License Number
FD
License Number
FD
SECTION D: CHANGE IN CORPORATE OFFICER(S) (Please note, CCR Section 1213 (b) states in part; any transfer, in a single transaction or
in a related series of transactions, of more than fifty percent (50%) of the equitable interest in the ownership of a licensed funeral establishment shall constitute a change of
ownership and shall require assignment of the funeral establishment license)
CORPORATE OFFICER(S) TO BE DISASSOCIATED FROM THIS ESTABLISHMENT
Title Last Name First Date of Disassociation
FOR BUREAU USE ONLY
Date Cashiered Amount Cashiered ATS ID Number Receipt Number
Affidavit’s
Received
Common
Ownership
Checked
Within 60
Miles
Application Approved Relate License
(If applicable)
New Establishment
License Ordered
(If applicable)
Duplicate Manager
License Ordered
(If required)
REV (07/20)
Cemetery and Funeral Bureau –www.cfb.ca.gov Page 1 of 3
SECTION D: CONTINUED
CORPORATE OFFICER(S) TO BE ASSOCIATED TO THIS ESTABLISHMENT
Title Last Name First Date of Association
ALL OFFICERS ARE REQUIRED TO SUBMIT A CERTIFICATION AFFIDAVIT WITH THIS APPLICATION
SECTION E: CHANGE IN PRENEED TRUSTEE(S)
PRENEED TRUSTEES TO BE DISASSOCIATED FROM THIS ESTABLISHMENT
Last Name First Date of Association
PRENEED TRUSTEES TO BE ASSOCIATED TO THIS ESTABLISHMENT (Only one Trustee can be an employee or officer of the Funeral
Establishment)
Last Name First Date of Disassociation
ALL TRUSTEES ARE REQUIRED TO SUBMIT A CERTIFICATION AFFIDAVIT WITH THIS APPLICATION
SECTION F: APPLICANT CERTIFICATION
(Must be signed by the owner, if a sole proprietorship; a partner, if a partnership; or a corporate officer, if a corporation, this application
may not be signed by the designated managing funeral director.)
I certify under penalty of perjury under the laws of the State of California that there has been no transfer, in a single
transaction or in a related series of transactions of more than 50% of equitable interest in the ownership of this licensed
funeral establishment and that all statements furnished in connection with this application are true and accurate
. (If an
equitable change has taken place, stop and contact the Bureau at (916) 574-7874.)
Signature Print Name
Title Date
REV (07/20) Cemetery and Funeral Bureau –www.cfb.ca.gov Page 2 of 3
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
Partner
Officer Trustee
Name of Funeral Establishment, Cemetery or Crematory this Affidavit is Being submitted with License Number of FD, CR or
COA (If applicable)
Funeral Establishment, Cemetery or Crematory Phone Number Residence Phone Number
( ) )
Last Name First Middle Initial
(
Residence Address Street 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.
Yes No
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 any other governmental authority in this state or any other state, or any foreign
country
Yes No
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 3 of 3
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 NOTIFICATION OF CHANGE SECTION A: ESTABLISHMENT INFORMATION (California)

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Completed 8 June 2021

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