FLORIDA DEPARTMENT OF FINANCIAL SERVICES TOM GALLAGHER CHIEF FINANCIAL OFFICER STATE OF FLORIDA . —, = IN THE MATTER OF: () 5 - O Ful S SAFE HARBOR MANAGEMENT CaseNos: 75159-04-FC SERVICES, INC., d/b/a AT PEACE 75160-04-FC CREMATION and ROBERT M. 71672-03-FC SHANNON, individually, and as President and Registered Agent. EX 20030900091, CP 20030600499 CP 20021100357, CP 20030600092 7 CP 20021100585 AUG i% 2004: Docketed py A teteon ADMINISTRATIVE COMPLAINT TO: Robert M. Shannon, President, Registered Agent Safe Harbor Management Services, Inc. 531 S. Pineapple, #10 Sarasota, Florida 34328 You, Safe Harbor Management Services, Inc. d/b/a At Peace Cremation (hereinafter “Safe Harbor”) and Robert M. Shannon (hereinafter “Shannon”) are hereby notified that, pursuant to Chapter 497, Florida Statutes, the Chief Financial Officer of the State of Florida has caused to be made an examination and investigations of your activities related to the sale and fulfillment of preneed funeral and cemetery services and merchandise. The Board of Funeral and Cemetery Services within the Department of Financial Services (hereinafter “Department”), found probable cause to charge you with violations of the provisions of Chapter 497, Florida Statutes, “The Funeral and Cemetery Services Act” (hereinafter “the Act”), as a result of which it is alleged: GENERAL ALLEGATIONS 1. Safe Harbor is a Florida profit corporation first licensed by the Department of Financial Services (hereinafter “the Department”) to sell funeral and cemetery preneed contracts (hereinafter ““COA”) pursuant to the Act on June 26, 1998. 2. In March of the year 1999, Safe Harbor acquired approximately 6,800 outstanding preneed contracts from the American Family Cremation Society (hereinafter “American Family”) receivership, with Board approval. Safe Harbor fulfills the American Family contracts at the time of need. If the money in trust is less than the contract amount, Safe Harbor can make a claim for the balance from the Preneed Funeral Contract Consumer Protection Trust Fund (hereinafter “Consumer Protection Fund”). The referenced fund is a stat utorily created trust fund administered and regulated by the Department, and funded by the regulated industry, for the purpose of providing restitution to preneed contract purchasers and their estates due toa certificateholder’s failure to provide the benefits of a preneed contract, or failure to refund the appropriate principal amount by reason of cancellation thereof. If a consumer requests cancellation of an American Family contract, Safe Harbor is required to refund only the amount of money deposited in trust for the particular contract. .f 3. In December of 1999, the Department, through its Regional Area Financial Manager, advised Mr. Shannon that he could not charge a fifty ($50.00) dolar fee for processing a request for cancellation and refund, and ordered him to stop the practice. Mr. Shannon acknowledged the warning in writing on December 22, 1999, stating that he would no longer charge a fee to cancel American Family contracts. 4. On October 18, 2002, Safe Harbor’s application for renewal of its COA was denied by final order. Safe Harbor continues to be licensed as a direct disposal establishment (license number 370) by the Department of Business and Professional Regulations, with its principal place of business at 513 South Pineapple, Suite 10, Sarasota, Florida, 33423-4135. 5. Robert W. Shannon is the president and registered agent of Safe Harbor. Although no longer authorized to sell preneed funeral and cemetery services and merchandise, Safe Harbor and Mr. Shannon have ongoing responsibilities to comply with the Act. Pursuant to the provisions of section 497.436, Florida Statutes, and Florida Administrative Code Rule 69K- 5.0025, a certificatcholder who becomes inactive must cease all preneed sales to the public, but continue to collect and deposit into trust one hundred percent (100%) of the funds paid toward preneed contracts sold prior to becoming inactive. The trust fund of the inactive certificateholder must be held intact, and the funds disbursed in accordance with the requirements of the written contracts until the funds have been exhausted. Mr. Shannon was advised of the requirements by letter dated November 19, 2002. 6. The Trustee of American Family’s preneed contract trust fund is Funeral Services Inc. (hereinafter “FSI”). 7. The Department continues to have the same jurisdiction over Safe Harbor pursuant to the Act as if the certificate were active, and to require appropriate reports and inspections as long as there are funds in trust or preneed contracts that are not fulfilled. COUNT I 8. The above allegations are hereby realleged and fully incorporated by reference. 9. On January 18, 1996, Samuel Jemison entered into a prearranged funeral agreement with American Family for a total price of five hundred forty-four dollars ($544.00). Of that amount, four hundred dollars ($400.00) was allocated to the service, including “transportation from place of death, temporary shelter of remains, completion of necessary documents, and death certificate, standard cremation container, cremation, return of cremated remains, and all staff services.” Ninety-five dollars ($95.00) was allocated to pre-funded society membership with travel protection, and forty-nine dollars ($49.00) was allocated to the provision of twelve death certificates. The full amount of the contract was paid on the same date. 10. The travel protection program provided that if a beneficiary died while away from the State of Florida, American Family would arrange for the deceased beneficiary to be transferred to an approved affiliate to provide the contract arrangements without any additional expense to the beneficiary’s family or estate. 11. Following Mr. Jemison’s death and cremation in May of the year 2003, Shannon sent a statement to Mr. Jemison’s relatives for additional charges of one hundred thirty ($130.00) dollars, along with a note stating, “Please pay this invoice then call for directions to pick up Mr. Jemison’s ashes.” The extra charges were for document procurement services ($40.00), a medical examiner cremation authorization fee ($40.00), and the cost to petition the state for reimbursement from the Consumer Protection Trust Fund. Five death certificates were included with the invoice. 12. Mr. Jemison’s remains were located and retrieved with the help of the state. IT IS THEREFORE CHARGED, that you, Safe Harbor Management Services, Inc., d/b/a At Peace Cremations, and Robert M. Shannon, have violated or are accountable under the following provisions of the Act and rules of the Department which constitute grounds for discipline: (a) Assessing fees that have not been disclosed to the customer. [Section 497.233(1)(t), Florida Statutes]; (b) Violating any provision of the Act. [Section 497.233(1)(a), Florida Statutes}; (c) Making a material misrepresentation for the purpose and intent of effecting settlement of a claim on less favorable terms than those provided in and contemplated by the prepaid contract. [Section 497.445(5)(b), Florida Statutes}; (da) Misrepresenting pertinent facts on prepaid contracts relating to coverage with such frequency as to indicate a general business practice. [Section 497.445(5)(c) 2, Florida Statutes]. COUNT TWO 13. The above allegations are hereby realleged and fully incorporated by reference. 14. A preneed contract purchaser can cancel the services, facilities and cash advance items of a preneed contract at any time before they have been used, and shall be entitled to a full refund of the purchase price of such items. 15. Worth W. Couch purchased a preneed contract from American Family on April 19, 1997. On August 30, 2002, he cancelled the contract in writing. Mr. Shannon made a claim to FSI and received the full amount of the trusted principal attributable to Mr. Couch’s contract, two hundred forty-eight and 01/100 dollars ($248.01). Nearly nine months later, on May 10, 2003, Shannon issued a check in the amount of two hundred thirty-three and 01/100 dollars ($233.01) to Mr. Crouch, retaining twenty-five dollars ($25.00) as a cancellation fee. IT IS THEREFORE CHARGED, that you, Safe Harbor Management Services, Inc., d/b/a At Peace Cremations, and Robert M. Shannon, have violated or are accountable under the following provisions of the Act which constitute grounds for discipline: (a) Assessing fees that have not been disclosed to the customer. [Section 497.233(1)(t), Florida Statutes]; (b) Violating any provision of the Act. [Section 497.233(1)(a), Florida Statutes]; (c) Failing to make a complete refund of the services, facilities and cash advance portions of a preneed contract within 30 days of receipt of written notice of cancellation. [Section 497.419(2), (10), Florida Statutes]; (d) Making a material misrepresentation for the purpose and intent of effecting settlement of a claim on less favorable terms than those provided in and contemplated by the prepaid contract. [Section 497.445(5)(b), Florida Statutes]; (e) Misrepresenting pertinent facts on prepaid contracts relating to coverage with such frequency as to indicate a general business practice. [Section 497.445(5)(c) 2, Florida Statutes]. COUNT THREE 16. The above general and specific allegations are hereby realleged and fully incorporated by reference. 17. Herbert and Judith Medrow requested cancellation of their preneed contracts in writing on April 1, 2003. FSI provided two checks in the amount of two hundred ninety-seven dollars ($297.00) each to Shannon on May 6, 2003. ‘ 18. On June 11, 2003, Safe Harbor issued two checks to Herbert and Judith Medrow in the amount of two hundred seventy-two dollars (272.00) each, retaining a cancellation fee of $25.00 each. IT IS THEREFORE CHARGED, that you, Safe Harbor Management Services, Inc., d/b/a At Peace Cremations, and Robert M. Shannon, have violated or are accountable under the following provisions of the Act which constitute grounds for discipline: (a) Assessing fees that have not been disclosed to the customer. [Section 497.233(1)(t), Florida Statutes); (b) Violating any provision of the Act. [Section 497.233(1)(a), Florida Statutes]; (c) Failing to make a complete refund of the services, facilities and cash advance portions of a preneed contract within 30 days of receipt of written notice of cancellation. [Section 497.419(2), (10), Florida Statutes}; (d) Making a material misrepresentation for the purpose and intent of effecting settlement of a claim on less favorable terms than those provided in and contemplated by the prepaid contract. [Section 497.445(5)(b), Florida Statutes}; (e) Misrepresenting pertinent facts on prepaid contracts relating to coverage with such frequency as to indicate a general business practice. [Section 497.445(5)(c) 2, Florida Statutes]. COUNT FOUR 19. The above allegations are hereby realleged and fully incorporated by reference. 20. Antoinette Hohl purchased two preneed contracts for herself and Eugene H. Hohl in the amount of five hundred ten dollars ($510.00) each on April 29, 1997. A total of four hundred and twenty four ($424.00) dollars was paid on each contract; two hundred ninety-six and 80/100 ($296.80) was trusted for each contract. 21. The Hohls made written requests to cancel their contracts and receive refunds in June of the year 2002. 22. FSI disbursed two checks in the amount of two hundred ninety-six and 80/100 dollars ($296.80) each to Safe Harbor on June 18, 2002. 23. At Peace refunded five hundred fifty-three and 60/100 dollars ($553.60) to the Hohls, retaining fifty dollars in cancellation fees, on January 9, 2003. IT IS THEREFORE CHARGED, that you, Safe Harbor Management Services, Inc., d/b/a At Peace Cremations, and Robert M. Shannon, have violated or are accountable under the following provisions of the Act which constitute grounds for discipline: (a) Assessing fees that have not been disclosed to the customer. [Section 497.233(1)(t), Florida Statutes]; () Violating any provision of the Act. [Section 497.233(1)(a), Florida Statutes]; (c) Failing to make a complete refund of the services, facilities and cash advance portion of a preneed contract within 30 days of receipt of written notice of cancellation. [Section 497.419(2), (10), Florida Statutes]; (d) | Making a material misrepresentation for the purpose and intent of effecting settlement of a claim on less favorable terms than those provided in and contemplated by the prepaid contract. [Section 497.445(5)(b), Florida Statutes]; (e) Misrepresenting pertinent facts on prepaid contracts relating to coverage with such frequency as to indicate a general business practice. [Section 497.445(5)(c) 2, Florida Statutes]. COUNT FIVE 24. The above allegations are hereby realleged and fully incorporated by reference. 25, Safe Harbor fulfilled approximately seventy-nine preneed contracts in calendar year 2003. 26. Of the approximately seventy-nine contracts fulfilled in 2003, approximately sixty-six beneficiaries were charged at least one additional fee not disclosed in the preneed contract. The charges consisted of shipping and handling charges, document procurement charges, medical examiner cremation authorization charges, charges for filing a claim with the Consumer Protection Trust Fund, and miscellaneous charges. A copy of the spread-sheet itemizing the contracts and charges is incorporated herein and attached hereto as Exhibit “A.” 27. The smallest single charge made by Safe Harbor that is listed on Exhibit “A” was fourteen ($14.00) dollars for miscellaneous fees; the largest single charge was nine hundred forty ($940.00) dollars for miscellaneous fees. The $940.00 miscellaneous fee consisted of a three hundred twenty dollar ($320.00) charge for professional services, a two hundred dollar ($200.00) charge for transfer, a one hundred dollar ($100.00) charge for refrigeration, and a three hundred twenty dollar ($320.00) charge for cremation. All of the foregoing services were already included in a four hundred fifteen dollar ($415.00) fully paid preneed contract. 28. Trusted amounts in approximately fourteen out the seventy-nine contracts fulfilled in 2003 were disbursed to Safe Harbor, but there is no record that the services were ever performed. 29. Contract holders cancelled approximately twenty-one preneed contracts during calendar year 2003. Of these, approximately six were issued refunds directly from FSI. The remaining approximately fifteen refund checks were issued to Safe Harbor. In approximately six of the cases where refund checks were issued directly to Safe Harbor, a cancellation fee of twenty-five dollars ($25.00) was deducted before forwarding the balance to the customer. In one case, Safe Harbor deducted a cancellation fee of twenty dollars ($20.00). The remaining refund checks were retained by Safe Harbor and never refunded to the customer. A copy of the spread- _ sheet itemizing the cancelled contracts is incorporated herein and attached hereto as Exhibit “p> IT IS THEREFORE CHARGED, that you, Safe Harbor Management Services, Inc., d/b/a At Peace Cremations, and Robert M. Shannon, have violated or are accountable under the following provisions of the Act which constitute grounds for discipline: (a) Assessing fees that have not been disclosed to the customer. [Section 497.233(1)(t), Florida Statutes]; (b) Misrepresentation in connection with a preneed transaction. [Section 497.233(1)(i), Florida Statutes]; (c) Violating any provision of the Act. [Section 497.233(1)(a), Florida Statutes]; (d) Failing to make a complete refund of the services, facilities and cash advance portions of a preneed contract within 30 days of receipt of written notice of cancellation. [Section 497.419(2), (10), Florida Statutes]; (e) | Making a material misrepresentation for the purpose and intent of effecting settlement of a claim on less favorable terms than those provided in and contemplated by the prepaid contract. [Section 497.445(5)(b), Florida Statutes]; (f) Misrepresenting pertinent facts on prepaid contracts relating to coverage with such frequency as to indicate a general business practice. [Section 497.445(5)(c) 2, Florida Statutes]; WHEREFORE, you, Safe Harbor Management Services, Inc, d/b/a At Peace Cremations, and Robert M. Shannon, are hereby notified that the Department intends to enter an Order imposing such penalties as are provided under the provisions of sections 497.233(2), 497.435, 497.519, Florida Statutes, and Fla. Admin. Code R. 69K-11. 10 . NOTICE OF RIGHTS You have the right to request a proceeding to contest this action by the Department pursuant to sections 120.569 and 120.57, Florida Statutes, and Rule 28.107, Florida Administrative Code. The proceeding request must be in writing, signed by you, and must be filed with the Department within twenty-one (21) days of your receipt of this notice. Completion of the attached Election of Proceeding form and/or a petition for administrative hearing will suffice as a written request. The request must be filed with the General Counsel as acting Agency Clerk, at the Florida Department of Financial Services, 612 Larson Building, 200 East Gaines Street, Tallahassee, Florida 32399-0333. The Department must receive your written response no later than 5:00 p.m. on the twenty-first day after your receipt of this notice. Mailing the response on the twenty-first day will not preserve your right to a hearing. YOUR FAILURE TO RESPOND IN WRITING WITHIN TWENTY-ONE (21) DAYS OF YOUR RECEIPT OF THIS NOTICE WILL CONSTITUTE A WAIVER OF YOUR RIGHT TO REQUEST A PROCEEDING ON THE MATTERS ALLEGED HEREIN AND AN ORDER OF REVOCATION WILL BE ENTERED AGAINST YOU. If you request a proceeding, you must provide information that complies with the requirements of Rule 28-107.004, Florida Administrative Code. As noted above, completion of the attached Election of Proceedings form conforms to these requirements. Specifically, your response must contain: (a) The name and address of the party making the request, for purpose of service; (b) A statement that the party is requesting a hearing involving disputed issues of material fact, or a hearing not involving disputed issues of material fact; and (c) A reference to the notice, order to show cause, administrative complaint, or other communication that the party has received from the agency. 11 . Ifa hearing of any type is requested, you have the right to be represented by counsel or other qualified representative at your expense, to present evidence and argument, to call and cross-examine witnesses, and to compel the attendance of witnesses and the production of documents by subpoena. If a proceeding is requested and there is no dispute of material fact, the provisions of section 120.57(2), Florida Statutes, apply. In this regard, you may submit oral or written evidence in opposition to the action taken by the Department or a written statement challenging the grounds upon which the Department has relied. While a hearing is normally not required in the absence of a dispute of fact, if you feel that a hearing is necessary, one will be conducted in Tallahassee, Florida, or by telephonic conference call upon your request. Failure to follow the procedure outlined with regard to your response to this notice may result in the request being denied. All prior oral communication or correspondence in this matter shall be considered freeform agency action, and no such oral communication or correspondence shall operate as a valid request for an administrative proceeding. Any request for an administrative proceeding received prior to the date of this notice shall be deemed abandoned unless timely renewed in compliance with the guidelines as set out above. Mediation of this matter pursuant to section 120.573, Florida Statutes, is not available. No Department attomey will discuss this matter with you until your respohse is received by the Department of Financial Services. DATED: this / 7p vk day of August, 2004. Kou Ud KAREN CHANDLER Deputy Chief Financial Officer CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy of the foregoing ADMINISTRATAIVE COMPLAINT has been furnished to the person and entity at the addresses above listed by U.S. Certified Mail this_/ 2 ¢ =z day of August, 2004. } ey foe ee {Ae “> Aa Lésley Mendelson Florida Department of Financial Services Division of Legal Services 612 Larson Building Tallahassee, Florida 32399-0333 (850) 413-4110 Fla. Bar No. 97569 13 . At Peace Cremations Fulfilled contracts 2003 Original | Amounton Amount | Shipping &} Document Med. Examiner {| Petition State for Contract Amount of Master Disbursed | Handling | Procurement Cremation CPTF Misc. Extra | Total Extra Number | Beneficiary Name Contract | Receipt Difference | from FS! Charges Charges Authorization Reimbursement | fees charged | Fees Charge ee ee aes H | j 16-05717 | Kerstin M Dispirito __ $464.00 $559.00 $95.00 $344.00] _ | _ __ 80. 16.07917 | __ Harry H Long Jr $425.00) $136.50) | oe - $0. 16-09228 Margie D Lamb 3436.00 $204.63) | _ oo. 1% 3] Denna Alen! $517.00 ~~ i E : i ft i 16-1. 9 | Lawrence M Gephart | __ 3524.00) ~ $249.20) I en 16-11795_ [~~ Elizabeth H Hur 30.00| $274.40) _ a TO-13513 GailM Rice $529.00 ___ $293:36| a i Z __ __ - 16-13529 jas E White $500.00 ~ ~ ~~ 1 _. 16-13532 Patrick Heppes $500.00 ~ ~— 16-13535 James T Henry |~”_ $521.00; “I - ~ 16-13667 |" Ralph C McMaster $600 001 { a i 16-14825 Fred C Brink | in | 16.05657 | Elaine Leighton $425.00 $520.00 $305.00 $40.00) $40.00 16-05671 | James Ed Nyshta $412.00 $507.00 $0.00 $30.00! $30.00 $412.00) 16-03838"[”_ Robert H Knotts $400; $495.00 $286.00 375.00 $40.0 $40.00) 16-0: “amis Tillman $413.00 3115.08 $40.00; $40.00) ~ 16-05964 | Elwood O Rankin _ [~~ ~$520.00; $520.00] ~~ 5126.00! __‘$75.00[ — ~_ $30.00} $30.00] 16-06009 [~ Walter 5 Skwarok “$432.00 $527.00] $312.00 375.001 $40.00) ~_ 340.00} ~ T6-06065" |" Marie O R McGee 3425.00 $305.00) $75.00] $30.00] $30.00} “T6-07207 Philip G Daher [~ $474.00; $579.00 $304.00) $40.00) $40.00 ~~ $160.00 16 “Dorothy E Mahar . $236.20 330.00) 330.00] “Tet ‘Albert E Woodmanses $152.29] ~~ 330.00} 340.00" 321.00} 16-07568 RuthT Dunn | $310.00] $75.00} Tr ~ Y6-07892 Ruth A Qualeé f 6.00 ~ ~ $30.00 ~ $30.00} 16-07973 | Rudolph L Marasco ” $40.00 314.00 16-0799 Joan Stoltzner : 330.00 ~_ $30.00) { 16-08017 | Samuel M Jemison: $449.00) $544.00) $95.00 $40.00} $40.00) “T6-080 Joseph RBelvin | $445.00 3540.00, $95.00) ~_ $46.00 ~ $40.00] 16-08092 at red J Light 3415.00 | $940.00 "T6-08657 [Judith A Reyser ~~ $417.00 3512-00} 395.00 ~ 330.00) 330.00 16-08738 |" Elizabeth JHollady | ~~ $405.00 $500.00| ~~~ $95.00) i $30.00] 330.00 16-09173 Lorena C Strow $440.00 $320.00) $30.00) $395.00 T6-O5312 ‘Adrian Ame $406.06} $286.00 340.00 $40.00 EXHIBIT Page 1 of 3 fA | Amount on Amount | Shipp ng &! Document | Med. Examiner { Petition State for ! Contract | | Amountof | Master | | Disbursed | Handiing | Procurement { Cremation CPTF Misc. Extra | Total Extr Number | Beneficiary Name Contract Receipt Difference { from FSt Charges Charges Authorization Reimbursement | fees charged | Fees Charg 16-09389 Carl L Crum $436.00 $531.00; $95.00 3154.36] 16-09432 | Adolphe Monosson $400.00 $49.60) + 16-0044 1 Marie i Kimball $495.00, $543.00! 395.00 3328.00; T6-09545 Jo Ann Keams | $0.00 $52.50) 16-096TT | Margaretta A Nyisztor| $593.00 {$156.75 16-09622 Evelyne E Farr 3415.00; — $51.34 375.00] 16-09686 | __ Mildred L Krygier 3695.00 3419.00] . 16-0789 | Dorothy MNewcomb | $425.00 $520.00; $95.00) $157.50} 375.00) O71 Howard C Johnson | $443.06 $328.00; $75.00) 16-v7683 Mary P Kooistra $352.00) ~ ~ $236.00) _ T6-09909 Mary R Sandlin $406.00 $501.00 395.00 3286.00] . - 16-09975 | Gertrude L Welch $540.00] ~ $635.00 395.00 S197.16| “Tt 16-1035T | Rudolph J Kostyal $525,001 3194.10) I T6-10335_| “Walter B Bachmann $536.00, $631.00 395.00 $188.36] 18-10391 Betiy R Likert $540.00 $635.00 395.00 $390.00] $75.00 610442 Wis E Sint 3525.00, [L___ $208.60) 16-10736 | Marjorie P Williamson! $536.00 $77.34 16-10894 |" Butord L Browning $300.00[ $625) 375.00] 16-10922 |" “John W Schiee, HI $524.00 ~ $163.80) s T6-10975 LN Woods ~$560,00) $655.00) $95.00 $3.50] T6-11017 |“ Goditey W Weese "$500.00! $595.00] $93.00 $119.03} ~ 375.00 “3100.00 T6-11448 |" “Edward R Takacs $524.00 $237.02! 16-1469 Pearl J Bowlin; 3510.00) - $165.64) . - ~ $75.00 Y6-11826 Marlene A Sack $545,00| ~~ $640.00) $95.00) $395.00} : ~T6-12180 |" “Charles WRollason $51Z,00) $607.00| ~~~ “$95.00 378.40) ~ 16-12250 [~~ Rena N Potts 3306-00," $601.00[_ $95.00} 33.50 - - “T6-12264 [Arthur S Anderson 3516.00 3611.00; ~~ $95.00 $5.50) 375,00} ~ “16 7 {7 _Tospeh K Haris $500.00 ~ 3595.00; $95.00) $150.50] a - —T6-...v8 [~~ Thomas J Kelly SIUT-00 3796.00," $95.00|__ $33.33 $75.00) ~~ 16-12964 |” Walter D Read Jr ; | 3218.40) | 7 —16-13223_| Betty RCumbie $318.00] $613.00] ~~ $95.00[_ $317.03 - 16-1347 Stanley E Ebert $500.00} $595.00|_ 395.00, $245.00 16-13479 | Cait ton $516.00 _ | s3a552f 16-T3579 | Winifred E Paisley’ $704.00 — $368.45 $75.00) 16-13580 | Jospeph C Kinney $532.00 3627.00 $95.00) $3304 ~ “T6-13747 sy LL Villa $895.00| ~~ $425.00) —~ ~ 16-3806 | Evelon C McConmick $510.00| $605.00! $95.00} $326.90 “T6-14076 |__ Terry L Larkins $516.00 | 3316.68] — 16-14134 | Harvey S Gardner “3542.00, $637.00 $95.00 $348.10) 375.00! — 16-14146 | _.Emily MDart $300.00 $355.00 395.00 3280.70 $75.00 16-14297 | Matilda Maleckar $600.00 3420.00) i $30.00 Page 2 of 3 Amount on Amount | Shipping &| Document | Med. Examiner | Petition State for | | Contract | Master } Disbursed { Handiing | Procurement Cremation CPTF Misc. Extra | Total Extr Number | Beneficiary Name | Contract Receipt Difference | from FSi Charges | Charges Authorization Reimbursement | fees charged | Fees Charg ee Oe 16-14382 Russell A Brock $616.00! $711.00 $95.00 $436.00; $40.60 $40.00! $50.00; $221.00) $35 16-14445 | Barbara J Bums 3620.00 $398.62 375.60| $30.00) $30.00; $50.00 SI: 16-14686 | Marina Diaz $600.00} H $420.00; $40.60) $40.00 _ $50.00; 313¢ 16-14839 | Jean Exton $607.00 $427,001 . $30.00 $30.00! $50.00) S11 16-15286 Vivian H Phillips $615,00 $710.00 $95.00) $412.11 H $30.00; I $50.00: $8( | { Totals $37,925.00] $22,458 oot $3,525.00] $1 8,784.46] $1,455.00} $2,100.00; $2,200.00) $3,135.00! $2,949.00] $11,836 Page 3 of 3 At Peace Cremations Canceled contracts 2003 . Amount Difference Total amount Disbursed from | Disbursed frum | Amount disbursed from | Nontrusted portion owed to consumer less Disbursement Contract # “Name FSI FSI to At Peace | At Peace to consumer owed to consumer total received check issued to 16-05649 Thelma H Conard $305.00 $305.00 $0.00 5305.00 At Peace 16-08381 James J Deweerdt $136.66 $136.66 $111.66 $0.00 $25.00 At Peace 16-08543 Dorothy E Bader $312.00 $312.00 $0.00 5312.00 At Peace 16-09383 _ Betty E Guise $196.00 $196.00 $0.00 [ $196.00 At Peace 16-09384 Thomas D Guise $171.50 $171.50 $0.00 $171.50 At Peace 16-09496 Herbert R Medrow $297.00 $297.00 | $272.00 $0.00 525.00 At Peace 16-09497 Judith G Medrow $297.00 $297.00 $272.00 $0.00 525.00 At Peace 16-10896 Edith § Walcome $3.50 $3.50 At Peace 16-10897 Robert F Walcome $3.50 $3.50 At Peace 16-12339 Joy R Speight $186.20 $186.20 5186.20 At Peace 16-12363 John W Speight $186.20 $186.20 $0.00 $186.20 At Peace ? 16-13246 Noel H Rice $293.30 $293.30 $273.30 $5.40 At Peace 16-13689 a Doris E McCall $350.00 $350.00 $325.00 $0.00 $25.00 At Peace 16-13690 Richard G McCall $350.00 $350.00 $325.00 BY $25.00 At Peace 16-14406 Mary Jo Pappathomides $455.00 $455.00 $430.00 $0.00 $25.00 At Peace 16-09190 Ana J Leon $31.50 . . $6.00 56.00 Consumer 16-09363 Louise F Groen $101.50 7 $0.00 | $0.00 Consumer | 16-09364 Don M Groen $101.50 i_ $0.00 $0.00 |___ Consumer 16-09562 John J isenmann $59.50 $0.00 $0.00 Consumer 16-14620 Evelyn M Brosscau_— | $450.00 $19.50 519.50 ; Consumer 16-14621 Edward W Brosscau i $449.00 $19.50 $19.50 Consumer | = Totals L $4,735.86 $3,542.86 | $2,008.96 | $50.40 $1,584.50 EXHIBIT

Docket for Case No: 05-000845