Contents
The Georgia C 15 form serves as a critical tool for funeral homes and registrants involved in the preneed funeral contract industry. This report, mandated by O.C.G.A. 10-14-12(g), requires the submission of an itemized list detailing all unserviced preneed funeral contracts as of December 31st of each year. By collecting essential information, such as the total number of unserviced contracts, the names of contract holders, and financial details, the form aims to ensure transparency and accountability within the sector. Funeral homes must provide their registration number, contact information, and the location of their records, facilitating easier communication and oversight. Additionally, the form includes a certification section, where the signatory affirms the accuracy of the report under penalties of perjury, thereby reinforcing the importance of honesty in reporting. The structured layout of the C 15 form, including multiple parts dedicated to general information and specific contract details, allows for thorough documentation and the possibility of attaching additional pages as needed. This comprehensive approach not only aids regulatory compliance but also promotes trust among consumers and the industry as a whole.
Georgia C 15 Example
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STATE OF GEORGIA |
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Brian P. Kemp |
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SECURITIES AND BUSINESS REGULATION |
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Robert D. Terry |
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Secretary of State |
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2 Martin Luther King Jr. Drive, S.E. |
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Division Director |
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Suite 802 West Tower |
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Atlanta, Georgia 30334 |
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(404) |
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REPORT AND ITEMIZED LIST OF ALL UNSERVICED PRENEED FUNERAL CONTRACTS |
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AS OF 12/31/200__ |
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This report is mandated by O.C.G.A. |
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Please read instructions accompanying this form. |
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PART 1 - GENERAL |
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Registration Number |
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Total number of unserviced |
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Phone Number |
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contracts as of |
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Name of Registrant/Funeral Home |
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Mailing Address |
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Zip Code |
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Location of Records |
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Zip Code |
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Name and phone number of contact person regarding this report: |
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PART II - UNSERVICED PRENEED FUNERAL CONTRACTS |
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Contract Holder Name and |
Depository |
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Date of |
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Contract |
Total Amount |
Amount |
Total Amount |
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Bank Account Number |
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Contract |
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Number |
of Contract |
Paid to Date |
on Deposit |
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TOTAL (Page 1) |
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TOTAL (Page 2) |
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TOTAL OF ALL PAGES |
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Attach additional pages, as necessary, with complete information as above on every contract holder.
Form |
page 1 |
PART II - UNSERVICED PRENEED FUNERAL CONTRACTS
Contract Holder Name and |
Depository |
Date of |
Contract |
Total Amount |
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Amount |
Total Amount |
Bank Account Number |
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Contract |
Number |
of Contract |
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Paid to Date |
on Deposit |
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TOTAL (Page 2) |
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Attach additional pages, as necessary, with complete information as above on every contract holder. |
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PART III - CERTIFICATION |
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I hereby certify, under penalties of perjury, that the information contained in this Annual Report and the supporting documents attached hereto are true and correct to the best of my knowledge and belief. I further certify that all required deposits have been made
to the preneed escrow account. I am authorized to sign this document on behalf of the individual or corporate owner.
Signature: |
Print Name: |
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Date |
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Form |
page 2 |
Document Breakdown
| Fact Name | Details |
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| Governing Law | The Georgia C 15 form is governed by O.C.G.A. § 10-14-12(g). |
| Purpose | This form reports unserviced preneed funeral contracts as of December 31 each year. |
| Filing Requirement | Funeral homes must file this report annually to comply with state regulations. |
| Contact Information | Registrants must provide a contact person's name and phone number on the form. |
| Registration Number | The form requires the registrant's registration number for identification. |
| Contract Details | Each contract listed must include details like the contract holder's name and total amount. |
| Certification Requirement | A certification section requires the signer to affirm the truthfulness of the information provided. |
| Submission Address | The form should be submitted to the Georgia Secretary of State's office in Atlanta. |
| Additional Pages | Additional pages can be attached if there are more contracts than fit on the initial form. |
| Form Version | The current version of the form is C-15, dated January 2010. |
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