Nebraska Department of Insurance

---

---

Complaint made by (Please provide your name, your mailing address, and your work and home phone numbers):

Last Name: First Name: MI:
Address:
City: State: Zip Code:
Home Phone Number: Work Phone Number:

---

Complaint is Directed Against: (Pre-Need Establishment's Name)

Trustee for the Pre-Need Trust: (Financial Establishment Holding the Pre-Need Trust)

Pre-Need Burial Trust Type:

Irrevocable Revocable

Pre-Need Agreement Date:
Total Agreement Amount:
Total Amount of Funds Paid to Pre-Need Seller:

Summary of Complaint: (Please itemize and specifically discuss each problem)