INDIGENT BURIAL - PROGRAM ELIGIBILITY ASSETS CHECKLIST

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1 INDIGENT BURIAL - PROGRAM ELIGIBILITY Eligibility for the Indigent Burial Program is NOT automatic. Eligibility is based on income and assets of both the decedent and next of kin. The Decedent and the next of kin must both qualify. Final determination of qualification rests with the Ravalli County Commissioners. A copy of the death certificate with decedent s information is available at the office of the Clerk & Recorder. DECEDENT NAME: DATE OF DEATH: Veteran burial benefits are separate. Please contact a local funeral home. ASSETS Certificate(s) of Deposit (CD) Investment Account(s) IRA, Keogh, 401K or other Retirement account(s) Trust(s) Gold, Silver, Gems Real Estate Disability Benefits Lawsuits Boat(s),Motorcycle(s), Snowmobile(s),4 Wheeler(s), RV(s) Firearm(s) Livestock CHECKLIST Information to determine eligibility is taken on the decedent and his/her spouse, if married. If the decedent was under 18 years of age, then eligibility is taken on the parent(s). The following information is needed to determine eligibility under the Indigent Burial Program: ID (ex: Driver s License, Picture ID, Voter Registration Card, etc.) Proof of income from the past 3 months. (example: A print-out sheet from unemployment compensation) W-2 Statement, 3 months check stubs, or a letter verifying 3 months of income, or a wage form completed by the decedent s employer(s), if the decedent was employed. Statement of pension benefits, etc. Current lease, past 3 months rent receipts, or a statement verifying living arrangement. If the decedent owned property, then a legal description of the property is required. (example: tax statement) Proof of checking and/or saving account values, stocks and/or bonds and certificate of deposit, if applicable. Proof of life insurance, if applicable If the decedent was in a nursing home, statement from the nursing home verifying date of admission. NOTES:

2 Statement of Monthly Income DECEDENT NEXT OF KIN Unemployment Comp. $ Unemployment Comp. $ Worker s Compensation $ Worker s Compensation $ Social Security $ Social Security $ Child Support $ Child Support $ VA Benefits $ VA Benefits $ Monthly Expenditures Housing Rent or Mortgage $ Utilities $ Family Resources Liquid Assets (Ex: Bank Accounts, Stocks, Bonds, CDs, etc.) Cars / Trucks Bank Account: Location: Balance: Vehicles #1 Model Year Debt Owed $ #2 Model Year Debt Owed $ #3 Model Year Debt Owed $

3 EMPLOYMENT HISTORY Please list employment in your household for present and previous employers. APPLICANT / HEAD OF HOUSEHOLD / OTHER HOUSEHOLD MEMBERS Except for the limited purposes of the Indigent Burial program, Ravalli County does not provide supplemental assistance for funeral services. If funds or assets of the decedent or of the estate of the decedent, in excess of those disclosed herein are identified, the estate of the decedent and anyone obligated to reimburse Ravalli County under , MCA, shall be obligated to reimburse Ravalli County up to any amount provided for burial services plus costs. By executing this program eligibility application, applicant authorizes any representative of the decedent, including any executor, administer, or personal representative, and any representative of the estate, including the Ravalli County Public Administrator or other attorney, to directly reimburse Ravalli County. I/We understand that by signing this application, I/we swear that the information provided is true and accurate to the best of my/our knowledge. I/We further authorize Ravalli County to conduct an investigation for the purposes of verifying the information and also for the purpose of determining eligibility under the Indigent Burial Program. Applicant Printed Applicant Printed

4 INDIGENT BURIAL - PROGRAM ELIGIBILITY Eligibility for the Indigent Burial Program is NOT automatic. Eligibility is based on income and assets of both the decedent and next of kin. The Decedent and the next of kin must both qualify. Final determination of qualification rests with the Ravalli County Commissioners. A copy of the death certificate with decedent s information is available at the office of the Clerk & Recorder. DECEDENT NAME: DATE OF DEATH: Veteran burial benefits are separate. Please contact a local funeral home. ASSETS Certificate(s) of Deposit (CD) Investment Account(s) IRA, Keogh, 401K or other Retirement account(s) Trust(s) Gold, Silver, Gems Real Estate Disability Benefits Lawsuits Boat(s),Motorcycle(s), Snowmobile(s),4 Wheeler(s), RV(s) Firearm(s) Livestock CHECKLIST Information to determine eligibility is taken on the decedent and his/her spouse, if married. If the decedent was under 18 years of age, then eligibility is taken on the parent(s). The following information is needed to determine eligibility under the Indigent Burial Program: ID (ex: Driver s License, Picture ID, Voter Registration Card, etc.) Proof of income from the past 3 months. (example: A print-out sheet from unemployment compensation) W-2 Statement, 3 months check stubs, or a letter verifying 3 months of income, or a wage form completed by the decedent s employer(s), if the decedent was employed. Statement of pension benefits, etc. Current lease, past 3 months rent receipts, or a statement verifying living arrangement. If the decedent owned property, then a legal description of the property is required. (example: tax statement) Proof of checking and/or saving account values, stocks and/or bonds and certificate of deposit, if applicable. Proof of life insurance, if applicable If the decedent was in a nursing home, statement from the nursing home verifying date of admission. NOTES:

5 Statement of Monthly Income DECEDENT NEXT OF KIN Unemployment Comp. $ Unemployment Comp. $ Worker s Compensation $ Worker s Compensation $ Social Security $ Social Security $ Child Support $ Child Support $ VA Benefits $ VA Benefits $ Monthly Expenditures Housing Rent or Mortgage $ Utilities $ Family Resources Liquid Assets (Ex: Bank Accounts, Stocks, Bonds, CDs, etc.) Cars / Trucks Bank Account: Location: Balance: Vehicles #1 Model Year Debt Owed $ #2 Model Year Debt Owed $ #3 Model Year Debt Owed $

6 EMPLOYMENT HISTORY Please list employment in your household for present and previous employers. APPLICANT / HEAD OF HOUSEHOLD / OTHER HOUSEHOLD MEMBERS Except for the limited purposes of the Indigent Burial program, Ravalli County does not provide supplemental assistance for funeral services. If funds or assets of the decedent or of the estate of the decedent, in excess of those disclosed herein are identified, the estate of the decedent and anyone obligated to reimburse Ravalli County under , MCA, shall be obligated to reimburse Ravalli County up to any amount provided for burial services plus costs. By executing this program eligibility application, applicant authorizes any representative of the decedent, including any executor, administer, or personal representative, and any representative of the estate, including the Ravalli County Public Administrator or other attorney, to directly reimburse Ravalli County. I/We understand that by signing this application, I/we swear that the information provided is true and accurate to the best of my/our knowledge. I/We further authorize Ravalli County to conduct an investigation for the purposes of verifying the information and also for the purpose of determining eligibility under the Indigent Burial Program. Applicant Printed Applicant Printed

7 INDIGENT BURIAL - PROGRAM ELIGIBILITY Eligibility for the Indigent Burial Program is NOT automatic. Eligibility is based on income and assets of both the decedent and next of kin. The Decedent and the next of kin must both qualify. Final determination of qualification rests with the Ravalli County Commissioners. A copy of the death certificate with decedent s information is available at the office of the Clerk & Recorder. DECEDENT NAME: DATE OF DEATH: Veteran burial benefits are separate. Please contact a local funeral home. ASSETS Certificate(s) of Deposit (CD) Investment Account(s) IRA, Keogh, 401K or other Retirement account(s) Trust(s) Gold, Silver, Gems Real Estate Disability Benefits Lawsuits Boat(s),Motorcycle(s), Snowmobile(s),4 Wheeler(s), RV(s) Firearm(s) Livestock CHECKLIST Information to determine eligibility is taken on the decedent and his/her spouse, if married. If the decedent was under 18 years of age, then eligibility is taken on the parent(s). The following information is needed to determine eligibility under the Indigent Burial Program: ID (ex: Driver s License, Picture ID, Voter Registration Card, etc.) Proof of income from the past 3 months. (example: A print-out sheet from unemployment compensation) W-2 Statement, 3 months check stubs, or a letter verifying 3 months of income, or a wage form completed by the decedent s employer(s), if the decedent was employed. Statement of pension benefits, etc. Current lease, past 3 months rent receipts, or a statement verifying living arrangement. If the decedent owned property, then a legal description of the property is required. (example: tax statement) Proof of checking and/or saving account values, stocks and/or bonds and certificate of deposit, if applicable. Proof of life insurance, if applicable If the decedent was in a nursing home, statement from the nursing home verifying date of admission. NOTES:

8 Statement of Monthly Income DECEDENT NEXT OF KIN Unemployment Comp. $ Unemployment Comp. $ Worker s Compensation $ Worker s Compensation $ Social Security $ Social Security $ Child Support $ Child Support $ VA Benefits $ VA Benefits $ Monthly Expenditures Housing Rent or Mortgage $ Utilities $ Family Resources Liquid Assets (Ex: Bank Accounts, Stocks, Bonds, CDs, etc.) Cars / Trucks Bank Account: Location: Balance: Vehicles #1 Model Year Debt Owed $ #2 Model Year Debt Owed $ #3 Model Year Debt Owed $

9 EMPLOYMENT HISTORY Please list employment in your household for present and previous employers. APPLICANT / HEAD OF HOUSEHOLD / OTHER HOUSEHOLD MEMBERS Except for the limited purposes of the Indigent Burial program, Ravalli County does not provide supplemental assistance for funeral services. If funds or assets of the decedent or of the estate of the decedent, in excess of those disclosed herein are identified, the estate of the decedent and anyone obligated to reimburse Ravalli County under , MCA, shall be obligated to reimburse Ravalli County up to any amount provided for burial services plus costs. By executing this program eligibility application, applicant authorizes any representative of the decedent, including any executor, administer, or personal representative, and any representative of the estate, including the Ravalli County Public Administrator or other attorney, to directly reimburse Ravalli County. I/We understand that by signing this application, I/we swear that the information provided is true and accurate to the best of my/our knowledge. I/We further authorize Ravalli County to conduct an investigation for the purposes of verifying the information and also for the purpose of determining eligibility under the Indigent Burial Program. Applicant Printed Applicant Printed

10 INDIGENT BURIAL - PROGRAM ELIGIBILITY Eligibility for the Indigent Burial Program is NOT automatic. Eligibility is based on income and assets of both the decedent and next of kin. The Decedent and the next of kin must both qualify. Final determination of qualification rests with the Ravalli County Commissioners. A copy of the death certificate with decedent s information is available at the office of the Clerk & Recorder. DECEDENT NAME: DATE OF DEATH: Veteran burial benefits are separate. Please contact a local funeral home. ASSETS Certificate(s) of Deposit (CD) Investment Account(s) IRA, Keogh, 401K or other Retirement account(s) Trust(s) Gold, Silver, Gems Real Estate Disability Benefits Lawsuits Boat(s),Motorcycle(s), Snowmobile(s),4 Wheeler(s), RV(s) Firearm(s) Livestock CHECKLIST Information to determine eligibility is taken on the decedent and his/her spouse, if married. If the decedent was under 18 years of age, then eligibility is taken on the parent(s). The following information is needed to determine eligibility under the Indigent Burial Program: ID (ex: Driver s License, Picture ID, Voter Registration Card, etc.) Proof of income from the past 3 months. (example: A print-out sheet from unemployment compensation) W-2 Statement, 3 months check stubs, or a letter verifying 3 months of income, or a wage form completed by the decedent s employer(s), if the decedent was employed. Statement of pension benefits, etc. Current lease, past 3 months rent receipts, or a statement verifying living arrangement. If the decedent owned property, then a legal description of the property is required. (example: tax statement) Proof of checking and/or saving account values, stocks and/or bonds and certificate of deposit, if applicable. Proof of life insurance, if applicable If the decedent was in a nursing home, statement from the nursing home verifying date of admission. NOTES:

11 Statement of Monthly Income DECEDENT NEXT OF KIN Unemployment Comp. $ Unemployment Comp. $ Worker s Compensation $ Worker s Compensation $ Social Security $ Social Security $ Child Support $ Child Support $ VA Benefits $ VA Benefits $ Monthly Expenditures Housing Rent or Mortgage $ Utilities $ Family Resources Liquid Assets (Ex: Bank Accounts, Stocks, Bonds, CDs, etc.) Cars / Trucks Bank Account: Location: Balance: Vehicles #1 Model Year Debt Owed $ #2 Model Year Debt Owed $ #3 Model Year Debt Owed $

12 EMPLOYMENT HISTORY Please list employment in your household for present and previous employers. APPLICANT / HEAD OF HOUSEHOLD / OTHER HOUSEHOLD MEMBERS Except for the limited purposes of the Indigent Burial program, Ravalli County does not provide supplemental assistance for funeral services. If funds or assets of the decedent or of the estate of the decedent, in excess of those disclosed herein are identified, the estate of the decedent and anyone obligated to reimburse Ravalli County under , MCA, shall be obligated to reimburse Ravalli County up to any amount provided for burial services plus costs. By executing this program eligibility application, applicant authorizes any representative of the decedent, including any executor, administer, or personal representative, and any representative of the estate, including the Ravalli County Public Administrator or other attorney, to directly reimburse Ravalli County. I/We understand that by signing this application, I/we swear that the information provided is true and accurate to the best of my/our knowledge. I/We further authorize Ravalli County to conduct an investigation for the purposes of verifying the information and also for the purpose of determining eligibility under the Indigent Burial Program. Applicant Printed Applicant Printed

13 INDIGENT BURIAL - PROGRAM ELIGIBILITY Eligibility for the Indigent Burial Program is NOT automatic. Eligibility is based on income and assets of both the decedent and next of kin. The Decedent and the next of kin must both qualify. Final determination of qualification rests with the Ravalli County Commissioners. A copy of the death certificate with decedent s information is available at the office of the Clerk & Recorder. DECEDENT NAME: DATE OF DEATH: Veteran burial benefits are separate. Please contact a local funeral home. ASSETS Certificate(s) of Deposit (CD) Investment Account(s) IRA, Keogh, 401K or other Retirement account(s) Trust(s) Gold, Silver, Gems Real Estate Disability Benefits Lawsuits Boat(s),Motorcycle(s), Snowmobile(s),4 Wheeler(s), RV(s) Firearm(s) Livestock CHECKLIST Information to determine eligibility is taken on the decedent and his/her spouse, if married. If the decedent was under 18 years of age, then eligibility is taken on the parent(s). The following information is needed to determine eligibility under the Indigent Burial Program: ID (ex: Driver s License, Picture ID, Voter Registration Card, etc.) Proof of income from the past 3 months. (example: A print-out sheet from unemployment compensation) W-2 Statement, 3 months check stubs, or a letter verifying 3 months of income, or a wage form completed by the decedent s employer(s), if the decedent was employed. Statement of pension benefits, etc. Current lease, past 3 months rent receipts, or a statement verifying living arrangement. If the decedent owned property, then a legal description of the property is required. (example: tax statement) Proof of checking and/or saving account values, stocks and/or bonds and certificate of deposit, if applicable. Proof of life insurance, if applicable If the decedent was in a nursing home, statement from the nursing home verifying date of admission. NOTES:

14 Statement of Monthly Income DECEDENT NEXT OF KIN Unemployment Comp. $ Unemployment Comp. $ Worker s Compensation $ Worker s Compensation $ Social Security $ Social Security $ Child Support $ Child Support $ VA Benefits $ VA Benefits $ Monthly Expenditures Housing Rent or Mortgage $ Utilities $ Family Resources Liquid Assets (Ex: Bank Accounts, Stocks, Bonds, CDs, etc.) Cars / Trucks Bank Account: Location: Balance: Vehicles #1 Model Year Debt Owed $ #2 Model Year Debt Owed $ #3 Model Year Debt Owed $

15 EMPLOYMENT HISTORY Please list employment in your household for present and previous employers. APPLICANT / HEAD OF HOUSEHOLD / OTHER HOUSEHOLD MEMBERS Except for the limited purposes of the Indigent Burial program, Ravalli County does not provide supplemental assistance for funeral services. If funds or assets of the decedent or of the estate of the decedent, in excess of those disclosed herein are identified, the estate of the decedent and anyone obligated to reimburse Ravalli County under , MCA, shall be obligated to reimburse Ravalli County up to any amount provided for burial services plus costs. By executing this program eligibility application, applicant authorizes any representative of the decedent, including any executor, administer, or personal representative, and any representative of the estate, including the Ravalli County Public Administrator or other attorney, to directly reimburse Ravalli County. I/We understand that by signing this application, I/we swear that the information provided is true and accurate to the best of my/our knowledge. I/We further authorize Ravalli County to conduct an investigation for the purposes of verifying the information and also for the purpose of determining eligibility under the Indigent Burial Program. Applicant Printed Applicant Printed

16 INDIGENT BURIAL - PROGRAM ELIGIBILITY Eligibility for the Indigent Burial Program is NOT automatic. Eligibility is based on income and assets of both the decedent and next of kin. The Decedent and the next of kin must both qualify. Final determination of qualification rests with the Ravalli County Commissioners. A copy of the death certificate with decedent s information is available at the office of the Clerk & Recorder. DECEDENT NAME: DATE OF DEATH: Veteran burial benefits are separate. Please contact a local funeral home. ASSETS Certificate(s) of Deposit (CD) Investment Account(s) IRA, Keogh, 401K or other Retirement account(s) Trust(s) Gold, Silver, Gems Real Estate Disability Benefits Lawsuits Boat(s),Motorcycle(s), Snowmobile(s),4 Wheeler(s), RV(s) Firearm(s) Livestock CHECKLIST Information to determine eligibility is taken on the decedent and his/her spouse, if married. If the decedent was under 18 years of age, then eligibility is taken on the parent(s). The following information is needed to determine eligibility under the Indigent Burial Program: ID (ex: Driver s License, Picture ID, Voter Registration Card, etc.) Proof of income from the past 3 months. (example: A print-out sheet from unemployment compensation) W-2 Statement, 3 months check stubs, or a letter verifying 3 months of income, or a wage form completed by the decedent s employer(s), if the decedent was employed. Statement of pension benefits, etc. Current lease, past 3 months rent receipts, or a statement verifying living arrangement. If the decedent owned property, then a legal description of the property is required. (example: tax statement) Proof of checking and/or saving account values, stocks and/or bonds and certificate of deposit, if applicable. Proof of life insurance, if applicable If the decedent was in a nursing home, statement from the nursing home verifying date of admission. NOTES:

17 Statement of Monthly Income DECEDENT NEXT OF KIN Unemployment Comp. $ Unemployment Comp. $ Worker s Compensation $ Worker s Compensation $ Social Security $ Social Security $ Child Support $ Child Support $ VA Benefits $ VA Benefits $ Monthly Expenditures Housing Rent or Mortgage $ Utilities $ Family Resources Liquid Assets (Ex: Bank Accounts, Stocks, Bonds, CDs, etc.) Cars / Trucks Bank Account: Location: Balance: Vehicles #1 Model Year Debt Owed $ #2 Model Year Debt Owed $ #3 Model Year Debt Owed $

18 EMPLOYMENT HISTORY Please list employment in your household for present and previous employers. APPLICANT / HEAD OF HOUSEHOLD / OTHER HOUSEHOLD MEMBERS Except for the limited purposes of the Indigent Burial program, Ravalli County does not provide supplemental assistance for funeral services. If funds or assets of the decedent or of the estate of the decedent, in excess of those disclosed herein are identified, the estate of the decedent and anyone obligated to reimburse Ravalli County under , MCA, shall be obligated to reimburse Ravalli County up to any amount provided for burial services plus costs. By executing this program eligibility application, applicant authorizes any representative of the decedent, including any executor, administer, or personal representative, and any representative of the estate, including the Ravalli County Public Administrator or other attorney, to directly reimburse Ravalli County. I/We understand that by signing this application, I/we swear that the information provided is true and accurate to the best of my/our knowledge. I/We further authorize Ravalli County to conduct an investigation for the purposes of verifying the information and also for the purpose of determining eligibility under the Indigent Burial Program. Applicant Printed Applicant Printed

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