EOED-DOL

Name of Funeral Establishment(Required)

Establishment License Number(Required)

Name(Required)

First Last

Name of Type 3 Registrant completing this form

License number(Required)

License number of Type 3 Registrant completing this form

Establishment Street Address(Required)

Street Address Address Line 2 City State ZIP Code

Establishment Mailing Address - IF Different from Above

Street Address Address Line 2 City State ZIP Code

Establishment Email Address(Required)

Total number of pre-need funeral contracts to which the funeral home is a Party(Required)

Identify the funding method used to finance each pre-need funeral contract listed in #1, above

Funeral (Bank) Trust Accounts(Required)

Pre-Need Insurance Policy or Annuities

Insurance Policy: Assigned, Changes of Ownership

Other (please specify or attach separate documentation)

Pursuant to 239 CMR 4.01

A pre-need funeral contract means any written agreement between a buyer and a funeral establishment in which the licensed funeral establishment agrees, prior to the death of a named beneficiary, to furnish funeral goods and/or services to that named beneficiary upon his or her death, and the buyer, pursuant to the agreement, transfers or tenders funds to the licensed funeral establishment for the purpose of paying all or part of the cost of those funeral goods and/or services at the time they are actually provided.

The number of pre-need funeral contracts entered into from 1/1/2025 to 12/31/2025:*(Required)

For all pre-need funeral contracts entered into from January 1, 2025 to December 31, 2025, provide the names and addresses of all banking institutions, trust companies, and insurance companies holding any funds received in connection with any such pre-need funeral contract(s). Please attach a separate sheet, if needed.

Company Name & Address(Required)

Company Name

Address

To add more than one entry, please choose the "+" sign next to Address.

The location in the Commonwealth of Massachusetts where your records of pre-need funeral contracts and arrangements are maintained (if kept on funeral establishment premises, indicate “on premises” only)

Address(Required)

Street Address

Address Line 2

City

State

Zip Code

The total number of pre-need funeral contracts and total amount of funds transferred to the Commonwealth of Massachusetts Treasurer in according with 239 CMR 409 (5) (c):

Total # of contracts transferred to the Treasurer(Required)

Total dollar value of contracts transferred to the Treasurer(Required)

Upload additional sheets as required

Drop files here or

Max. file size: 50 MB.

By entering your name below, you certify that the information contained in this report is true and accurate to the best of your knowledge and ability. You also certify that the funeral home complies with Board regulations at 239 CMR 3.17 relative to professional liability insurance requirements.

Name(Required)

First Last

Massachusetts Type 3 Registration Number(Required)