Ariz. Admin. Code § R4-12-565
STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
The charges are only for those items that are used. If we are required by law to use any items, we will explain the reasons in writing.
FUNERAL OF ____________________________________________
FORWARDING OF REMAINS TO ANOTHER FUNERAL HOME $__________
This charge includes removal of body, services of staff, necessary authorizations, embalming, and local transportation (but not shipping charges.)
RECEIVING OF REMAINS FROM ANOTHER FUNERAL HOME $__________
This charge includes services of staff, care of remains, and transportation to cemetery or crematory.
DIRECT CREMATION (As selected) $__________
This charge includes removal of body, necessary authorizations, services of staff, transportation to crematory, and cremation of body.
TRANSFER OF REMAINS TO FUNERAL HOME ( ________ miles transported) $__________
IMMEDIATE BURIAL (As selected) $__________
This charge includes removal of body, services of staff, necessary authorizations, and local transportation to cemetery.
FUNERAL ARRANGEMENTS (Indicated services and facilities selected) $__________
Funeral Director and Staff Services __________
Embalming __________
Other preparation of body __________
Use of facilities for viewing __________
Use of facilities for funeral __________
Other use of facilities __________
AUTOMOTIVE EQUIPMENT (Indicated items selected) $__________
Hearse __________
Limousine __________
Other automobiles __________
ACKNOWLEDGMENT CARDS $__________
CASKET SELECTED $__________
VAULT OR LINER $__________
OTHER ITEMS (describe)_____________________________ $__________
_____________________________ $__________
CASH ADVANCE ITEMS
Organist and/or other music $__________
Hairdresser or barber $__________
Flowers $__________
Pallbearers $__________
Motorcycle escorts $__________
Clergy Honoraria $__________
Obituary Notice $__________
Death Certificate(s) $__________
Gratuities $__________
Other (describe) $__________
Total $__________
TOTAL COST FOR ARRANGEMENTS SELECTED $__________
FOR FUNERAL HOME________________________________________ Date__________________________________
___________________________________________________________
Arranged by_________________________________________________ Date__________________________________
___________________________________________________________________
NOTICE TO PURCHASER
You may choose to purchase a casket or container for the funeral services and final disposition. However, except under certain public health circumstances pursuant to A.R.S. § 36-136, state law does not require the purchase or use of caskets or containers.
METHOD OF PAYMENT AND INTEREST CHARGES [describe the method of payment required by the funeral establishment for the funeral services and any interest charges.
[Statement not used as final bill]
Adopted effective January 1, 1985 (Supp. 85-1).
Adopted effective January 1, 1985 (Supp. 85-1). Appendix expired under A.R.S. § 41-1056(E) at 18 A.A.R. 607, effective December 29, 2011 (Supp. 12-1).
The corporate surety bond delivered to the Board with a prearranged funeral sales endorsement application shall contain the following language:
Adopted effective January 1, 1985 (Supp. 85-1).
ANNUAL REPORT
For Calendar Year Ending ____________
Name of Establishment ____________________________________________________________________________________________
Address________________________________________________________________________________________________________
___________________________________________________________________________________________ Zip ________________
Owners (owning a 10 percent or greater interest in the Establishment):
Name:____________________________________________ Name:_______________________________________________
Address:___________________________________________ Address:_____________________________________________
____________________________________________ ______________________________________________
Name:____________________________________________ Name:_______________________________________________
Address:___________________________________________ Address:_____________________________________________
____________________________________________ ______________________________________________
Funeral Establishment License No. ________________ Issued ________________
AFFIDAVIT
State of __________________
County ___________________
__________________________, being first duly sworn and upon [my] [our] oath, depose and state:
[I am] [We are] the owner(s) of ( establishment ) on behalf of which [I] [we] make this affidavit, being hereunto duly authorized. The funeral establishment herein named has complied with title 32, Chapter 12, Article 5 of the Arizona Revised Statues and the rules adopted pursuant to said Article. This Annual Report includes all prearranged funeral agreements sold or administered by this establishment. [I] [We] have read this Annual Report and accompanying Schedules A, B, C, D and E and know the contents thereof, and the matters and things therein stated are true and correct.
Subscribed and sworn to before me this ______ day of _______________, 19 _____.
_____________________________
Notary Public
5724A19 page 1
SCHEDULE A
Page ______
| PREARRANGED FUNERAL SALES DURING CALENDAR YEAR ENDING ______________ | Financial Institution Name ____________________ Address ___________________________________ Trust Account No.(s)*________________________ | |||||||||||
| PURCHASER NAME AND ADDRESS | SALE DATE | SALES PERSON | BENEFICIARY | TOTAL CONTRACT AMOUNT | INITIAL SERVICE FEE | INITIAL SERVICE FEE PAID | TOTAL MONIES PAID BY PURCHASER | TOTAL MONIES TO TRUST ACCOUNT | TOTAL REFUNDS MADE | BANK SERVICE CHARGES | OTHER WITH-DRAWALS (EXPLAIN)** | 12/31 TRUST ACCOUNT BALANCE |
Page Totals
| TOTALS |
|---|
* If this schedule concerns a number of trust accounts, provide names and addresses of financial institutions and list account numbers on separate sheet.
** If other withdrawals have occurred, explain in detail on separate sheet.
| 5806A1 | page 2 |
SCHEDULE B
Page ______
| EXISTING PREARRANGED FUNERAL AGREEMENTS SOLD BEFORE CALENDAR YEAR ENDING ______________ | Financial Institution Name ____________________ Address ___________________________________ Trust Account No.(s)*________________________ | |||||||||||
| PURCHASER NAME AND SALE DATE | TOTAL CONTRACT AMOUNT | INITIAL SERVICE FEE | INITIAL SERVICE FEE PAID | TOTAL MONIES PAID BY PURCHASER THIS YEAR | TOTAL MONIES PAID BY PURCHASER | TOTAL MONIES TO TRUST ACCOUNT | TOTAL REFUNDS PAID | ANNUAL SERVICE FEE | TAXES PAID | BANK SERVICE CHARGES | OTHER WITH-DRAWALS (EXPLAIN)** | 12/31 TRUST ACCOUNT BALANCE |
Page Totals
| TOTALS |
|---|
* If this schedule concerns a number of trust accounts, provide names and addresses of financial institutions and list account numbers on separate sheet.
** If other withdrawals have occurred, explain in detail on separate sheet.
| 5086A2 | page 3 |
SCHEDULE C
Page ______
| Financial Institution Name ____________________ Address ___________________________________ Trust Account No.(s)*________________________ | |||||||||
| SUMMARY OF TRUST ACCOUNT TRANSACTIONS FOR CALENDAR YEAR ENDING _______________ |
Total trust funds in account(s) on December 31 of previous calendar year.
| $ ______ | $ ______ | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Total funds received and deposited in trust account(s) during this calendar year. | $ ______ | ||||||||
| Total funds withdrawn from trust account(s) during this calendar year: | |||||||||
| 1) Funeral arrangements 2) Annual service fees 3) Tax payments 4) Financial institution service charges 5) Refunds to purchasers 6) Other withdrawals** TOTAL WITHDRAWALS | $ ______ $ ______ $ ______ $ ______ $ ______ $ ______ | $ ______ | |||||||
| Total interest paid to trust account(s) during this calendar year. | $ ______ | ||||||||
| Total trust funds in account(s) on December 31 of this calendar year. | $ ______ | ||||||||
| Total funds received for trust but not deposited in trust account(s) as of December 31 of this calendar year. | $ ______ |
* If this schedule concerns a number of trust accounts, provide names and addresses of financial institutions and list account numbers on separate sheet.
** If other withdrawals have occurred, explain in detail on separate sheet.
| 5724A20 | page 4 |
| SCHEDULE D SALESPERSONS EMPLOYED OR ENGAGED DURING CALENDAR YEAR | |||||||||
| Name | Address | Registration No. |
__________________________________
| __________________________________________ | __________________________________ |
__________________________________
| __________________________________________ | __________________________________ |
__________________________________
| __________________________________________ | __________________________________ |
__________________________________
| __________________________________________ | __________________________________ |
__________________________________
| __________________________________________ | __________________________________ |
__________________________________
| __________________________________________ | __________________________________ |
__________________________________
| __________________________________________ | __________________________________ |
__________________________________
| __________________________________________ | __________________________________ |
__________________________________
| __________________________________________ | __________________________________ |
__________________________________
| __________________________________________ | __________________________________ | ||||||||
| SCHEDULE E SALESPERSONS TERMINATED DURING CALENDAR YEAR | |||||||||
| Name | Registration No. |
___________________________________________________
| ___________________________________________________ |
___________________________________________________
| ___________________________________________________ |
___________________________________________________
| ___________________________________________________ |
___________________________________________________
| ___________________________________________________ |
___________________________________________________
| ___________________________________________________ |
___________________________________________________
| ___________________________________________________ |
___________________________________________________
| ___________________________________________________ |
___________________________________________________
| ___________________________________________________ |
___________________________________________________
| ___________________________________________________ |
| 5724A21 | page 5 |
Adopted effective January 1, 1985 (Supp. 85-1).
Adopted effective January 1, 1985 (Supp. 85-1). Section R4-12-565 recodified to R9-9B-326, at 32 A.A.R. 177 (January 9, 2026), effective January 1, 2026 (Supp. 25-4).