DISCLOSURE OF PRENEED FUNERAL AGREEMENT

The funeral establishment, Welch-Ryce-Haider Funeral Chapels, license number FD303

DoesDoes Not

have a preneed arrangement, as defined below, made by or on behalf of*

If the funeral establishment does have a preneed agreement, complete the following:

In compliance with Business and Professions Code Section 7745, the funeral establishment has presented to the person named below a copy of the preneed agreement which has been signed and paid for in full, or in part by, or on behalf of the deceased and is in the possession of the funeral establishment.*

Date

“Preneed Arrangement” “Preneed Agreement” or “Preneed” is written instruction regarding goods or services or both goods and services for final disposition of human remains in which the goods or services are not provided until time of death, and may be unfunded or may be paid for in advance of need. Under Business and Professions Code Sections 7685.6 and 7745, a copy of any preneed agreement made by, or on behalf of the decedent that is paid for in full or in part and is in the possession of the funeral establishment must be disclosed and presented to the survivor of the deceased who is handling the funeral arrangements, or the responsible party.

Funeral Establishment’s Responsibility — Business and Professions Code Section 7745 requires a funeral establishment to present to the survivor of the decedent or the responsible party a copy of any preneed agreement in its possession which has been signed and paid for in full, or in part by, or on behalf of the deceased. The funeral establishment may present the copy in person, by certified mail, or by facsimile transmission, as agreed upon by the person with the right to control disposition. A funeral establishment that knowingly fails to present a preneed agreement as required is liable for a civil fine equal to three times the cost of the preneed agreement, or one thousand dollars ($1,000), whichever is greater.

You may contact the Cemetery and Funeral Bureau for more information on funeral, cemetery or cremation matters or to file a complaint against a licensee: Cemetery and Funeral Bureau 1625 North Market Blvd., Suite S-208 800-952-5210 Sacramento, CA 95834 916-574-7870

Signature of Survivor or Responsible Party*

DATE*

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PRINT NAME OF THE SURVIVOR OR RESPONSIBLE PARTY*

The funeral establishment must: • Give a copy of the completed statement to the survivor or responsible party. • Retain the original completed disclosure statement on file for not less than one (1) year after the preneed account has been audited by the Bureau or seven (7) years from the date the disclosure statement was made, whichever comes first.