MORTUARY SCIENCE PRO GRAM
P.O. Box 64882, St. Paul, Minnesota 55164-0882
Telephone: (651) 201-3829/Fax: (651) 201-3839
Email: [email protected]
2015 Pre-Need Trust Fund Report Instructions
Minnesota Statutes §149A.97, subd. 7 requires that annual reports are submitted to the Commissioner of Health by all
funeral providers who accept funds for funeral or burial-site goods and services when those goods or services are not
delivered to the purchaser at the time of the sale. The Pre-Need Trust Fund Report must include all funds held in trust by
the funeral provider as required by Minnesota Statutes §149A.97, subd. 2. Funds held in insurance or annuity products
are exempt from the reporting requirement.
The Commissioner of Health will take appropriate enforcement action or refer the evidence discovered to another
appropriate enforcement agency if indications of violations of Minnesota Law are discovered during an audit process.
Pre-Need Submission Deadline
This report must be filed by March 31st each year with the Commissioner of Health, Mortuary Science section.
Pre-Need Filing Fee
A filing fee of $25 is required for each funeral provider that has trust fund accounts to report. Please make checks
payable to: Commissioner of Finance.
If you have no Pre-Need Trust Funds to report, there is no filing fee but you are still required to complete and submit the
Pre-Need Trust Fund Report Cover Sheet. To indicate that you have no Pre-Need Trust Funds to report, simply check the
“No” box and complete the remaining information to identify the funeral establishment(s).
Pre-Need Reporting Methods
While all funeral providers must submit a Pre-Need Trust Fund Report Cover Sheet, there are three ways to report PreNeed Trust information:
1. Pre-Need Trust Ledger. The ledger is enclosed.
2. Customized Pre-Need Form. As long as the information is consistent with that of the enclosed ledger form, a funeral
provider can submit their own customized form.
3. Pre-Need Excel Spreadsheet. The spreadsheet will be emailed to funeral providers by the Mortuary Science Section
by February 1st. To use this method, complete the spreadsheet and after saving the file for your records, print the
“Summary Sheet” from the spreadsheet and mail along with cover sheet to the Mortuary Science Section. Then
email a copy of the spreadsheet document to: [email protected]. The spreadsheet is also available on
Mortuary Science’s “Forms” web page. To download the form, visit:
http://www.health.state.mn.us/divs/hpsc/mortsci/forms.htm.
IMPORTANT:
▪
Our office is required to have an accountability of each funeral provider. Please list the names of all locations that
are included in the combined reports.
▪
Please be sure that all forms are totaled correctly, signed, and notarized where indicated.
▪
Any change of trustee of the trust fund must be filed with the Commissioner of Health, Mortuary Science Section,
within 30 days after a change has occurred.
If you require an alternate format (i.e., large print), please call (651) 201-3829. Printed on recycled paper.
REV. 01/29/2016
MORTUARY SCIENCE PRO GRAM
P.O. Box 64882, St. Paul, Minnesota 55164-0882
Telephone: (651) 201-3829/Fax: (651) 201-3839
Email: [email protected]
2015 Pre-Need Trust Fund Reporting Cover Sheet
This cover sheet must be completed and returned for all funeral providers (with or without pre-need trusted funds).
Mail this cover sheet, along with any supporting documentation to the address above. If you have any questions about
this form, you can contact our office at (651) 201-3829.
Instructions: List all funeral home and crematory licenses held and identify which have pre-need trust funds to report.
License No.
Provider Name
Pre-Need?
City
Yes
No
☐
☐
☐
☐
☐
☐
☐
☐
Number of funeral providers that have Pre-Need Trust Accounts to report:
Fee required: x $25.00
Total costs of filing fee(s): $
I, _______________________________________________, ________________________________ hereby certify that,
Name
Title
under penalty of perjury, to the best of my knowledge the information contained in this report is true and correct and
contains a complete and accurate report of all Pre-Need Trust Funds. I further certify that I am authorized to submit this
report on behalf of __________________________________________________________________________________.
Signature
Date
Subscribed and sworn to before me this _____________ day of ________________________, 2016.
Notary Public Signature
If you require an alternate format (i.e., large print), please call (651) 201-3829. Printed on recycled paper.
REV. 01/29/2016
MORTUARY SCIENCE PRO GRAM
P.O. Box 64882, St. Paul, Minnesota 55164-0882
Telephone: (651) 201-3829/Fax: (651) 201-3839
Email: [email protected]
Pre-Need Trust Ledger
Beneficiary
Date of Pre-Need Amount
Contract
Balance
Beginning Balance – January 1, 2015
$
Add: Deposits & Interests
$
Less: Withdrawals & Refunds
$
Ending Balance – December 31, 2015
$
Deposit
+ This Year
Subscribed and sworn to before me this __________ day of ________________, 2016.
Interest
+ This Year
Withdrawals
+ This Year
Balance at
= 12/31/2015
Account No./
Location
I, ________________________________, ___________________
Name
Title
hereby certify that, under penalty of perjury, to the best of my
knowledge the information contained in this report is true and
correct and contains a complete and accurate report of all PreNeed Trust Funds. I further certify that I am authorized to submit
this report on behalf of __________________________________.
Notary Public Signature
Signature
Date
If you require an alternate format (i.e., large print), please call (651) 201-3829. Printed on recycled paper.
REV. 01/29/2016