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DEPARTMENT OF
CONSUMER
AFFAIRS
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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
2021 PRENEED FUNERAL TRUST FUND
DECLARATION OF NON-REPORTING STATUS
Complete form and mail to the letterhead address; no fee is required.
Funeral Establishment Name: _________________________________________________
Funeral Establishment License Number: FD______________________________________
Reporting Period
(check one):
Calendar Year – Beginning January 1, 2021 and ending December 31, 2021
Fiscal Year – Beginning ____________________ and ending on __________________________
Final Report – Beginning ____________________ and ending on _________________________
The funeral establishment may file this Declaration based on the following (check all that apply):
The funeral establishment does not have any pre-need sales of funeral goods or services. (If this box is
checked, do not check any of the following boxes)
Pursuant to California Code of Regulations (CCR) Section 1261, the funeral establishment is exempt from
annual trust reporting requirements. The client/consumer directly deposits his or her own money in a bank or
savings institution trust account in the name of the client as trustee for the funeral establishment, provided that,
until death, the client retains the exclusive power to hold, manage, pledge, and invest the funds and may
revoke the tentative trust and withdraw the funds at any time. There is no delivery of money whatsoever to the
funeral establishment to pay for the services or goods until funeral goods and services have been provided.
The consumer purchases insurance for preneed funeral services and/or merchandise. The payments are made
payable by the consumer to the insurance company. The funeral establishment does not receive any cash or
money payable to them from the consumer for payments on the insurance policies, and does not deposit the
payments into their funeral establishment accounts. List insurance companies (i.e., Homesteaders, CNA,
etc.). _______________________________________________________________
The pre-need funeral trusts are administered under a common trust fund containing two or more funeral
establishments pursuant to CCR Section 1269(f). The funeral establishment has caused the trustee of the
common trust fund to file one combined annual report, which discloses the funeral establishment's information
separately. The combined report is filed by (trustee name(s):_____________________________________
I certify und
er penalty of perjury, under the laws of
the State of California, that the information presented
above is complete, true, and correct to the best of my
knowledge and belief.
AUTHORIZED SIGNATURE DATE
PRINT NAME TITLE
21 NR (REV 01/2021) Page 1 of 2
