Fillable Form 10PN003: Rev. 12/12 ANNUAL TRUSTEE REPORT FORM (Mississippi)

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Form 10PN003: Rev. 12/12 ANNUAL TRUSTEE REPORT FORM (Mississippi)

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Mail to: Post Office Box 136, Jackson, MS 39205-0136
Phone: 601-359-9055; Fax: 601-576-2546
Website: www.sos.ms.gov
ANNUAL TRUSTEE REPORT FORM
THIS REPORT IS FOR:
PRENEED FUNERAL/CEMETERY
SERVICES & MERCHANDISE TRUST
PERPETUAL CARE CEMETERY
TRUST
NOTE: This report is due no later than March 31
st
of each year and must be filed with the Secretary of
State. You are reporting on the prior ending calendar year, January 1, 20 ______ - December 31, 20______. Please
note, the last step for completing this form is the inclusion of a copy of the year end trust activity statement of the
fund as of December 31
st
.
A. Secretary of State Registration Number for the business for which you are reporting.
Obtain this information from the funeral home or cemetery.
____________________________________________________________________________________________
B. Name and location of funeral home or cemetery from which funds were received for trust.
If paper or ".pdf" submission is made, attach additional pages, if necessary.
____________________________________________________________________________________________
____________________________________________________________________________________________
NAME PHONE NUMBER
PHYSICAL LOCATION ADDRESS CITY STATE ZIP CODE
C. Name and address of trust officer submitting this report:
____________________________________________________________________________________________
NAME PHONE NUMBER
____________________________________________________________________________________________
TITLE AND INSTITUTION, IF APPLICABLE
Page 1 of 2
____________________________________________________________________________________________
PHYSICAL LOCATION ADDRESS CITY STATE ZIP CODE
Email Address of Trust Officer: __________________________________________________________________
Form 10PN003
Rev. 12/12
Print Form
STATE OF _________________________________
D. Date of trust agreement with provider: ________________________________________________________
E. Statement of Changes in Trust Balance:
1. Beginning Balance on January 1
2. Ending Balance on December 31
3. Received from provider:
4. Trust Earnings realized this year
(interest, dividends, capital gains/losses, etc.)
5. Tax Paid by Fund in Calendar Year
6. Management Fees Paid From Trust
$___________________
$___________________
$___________________
$___________________
$___________________
$___________________
F. FOR PERPETUAL CARE TRUSTEES ONLY
Investment Income/Interest Withdrawn from Trust in prior year
G. FOR PRENEED TRUSTEES ONLY
Total Death Claims Paid to Provider in prior calendar year
$___________________
$___________________
H. I have enclosed with this report a copy of the trust fund financial activity statement that
verifies the balance for the amount reported on December 31
st
.
CERTIFICATION OF TRUSTEE
Page 2 of 2
COUNTY OF _______________________________
I, __________________________________, (Print Name) of
________________________________________ (Company/Firm) trust officer for the Reporting Fund, being
first duly sworn, do hereby state that the information contained in this annual report and all related
schedules are true and correct to the best of my knowledge and belief.
______________________________________
TRUSTEE'S SIGNATURE
Sworn to and subscribed before me this the ___ day of_______________, 20___.
_____________________________________ _____________________________________
COMMISSION EXPIRES Notary Public
Form 10PN003
Rev. 12/12
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Form 10PN003: Rev. 1212 ANNUAL TRUSTEE REPORT FORM (Mississippi)

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Completed 2 February 2021

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