Burial Assistance Application

Transcription

1 Copper River Native Association (AHTNA T AENE NENE ) Mile Richardson Highway P.O. Box H. Copper Center, Alaska Phone (907) Fax (907) gjackson@crnative.org Website: Burial Assistance Application 1. Complete Application Form (Must be submitted within 30 days following death.) 2. Proof of Tribal Membership (for the deceased) 3. Proof of Residence in Service Area (deceased must have lived in the service area for 6 months) 4. Application Submitted to State of Alaska Burial Assistance (A deceased person who was receiving Adult Public Assistance or TANF/ATAP will have their burial assistance provided through the State of Alaska, per section of the State of Alaska General Relief Assistance (GRA) Manual. These persons are automatically not eligible for BIA funded Burial Assistance.) 5. Proof of Insufficient Resources (deceased s income; life insurance; ANY DONATIONS, including Native Corporations, Tribal Organizations and community; burial assistance from any other source.) 6. Release of Information (AS NEEDED signed by applicant) 7. Death Certificate (We will accept an obituary, coroner s report or Priest/Clergy letter, TEMPORARILY until you have this document.) ***ANY MISSING DOCUMENTS WILL DELAY THE PROCESSING OF THIS APPLICATION*** Name of Deceased: Deceased s of Birth: / / of Death: Deceased s Physical P.O. BOX NOT ALLOWED City State Zip Tribe Enrolled To: Tribal Enrollment #: ***The deceased must have resided in the service area for at least six (6) months*** Name of Applicant: Mailing Person applying on behalf of deceased Relationship to Deceased: Home Phone: Message Phone: Work Phone:

2 What arrangements have been made for the burial? Name of Mortuary: Contact Person: Phone: Fax: Please have them send an Invoice of the cost to the TCS Intake Specialist or TCS Case Manager. Were there cost related to transporting the body? Please explain: Will the casket be built? Yes No If yes, by whom? Please write information below. Name: Phone: Building Material Cost: $ Invoice Needed Cost not to exceed amount of casket fence cost is not allowable. (Attach Receipts) The Vendor is the person handling the financial aspects of the burial. We are asking for this information to issue a check for the Funeral Feast/Potlatch Food. The Funeral Feast will not exceed $ and will only be allowed if there is money left over after paying the burial cost. Vendor Name: Phone: Fax: Alternate Contact Person: Phone:

3 Record of Income and Resources Did the DECEASED have income from any source? Yes No (All income of the deceased for the month the death occurred.) If yes, please list source of income and amounts below. ***Applicant MUST provide proof of ALL income received & reported*** SOURCE OF INCOME & RESOURCES AMOUNT Salary #1: Applicant s Income/Salary $ Salary #2: Spouse s Income/Salary $ *Adult Public Assistance $ *State of Alaska ATAP/Tribal TANF $ *Public Assistance Burial Funds $ Social Security (SSA) (SSI) (SS Retirement) $ Disability Insurance $ Pension or Retirement (Including Cash Outs) $ State Longevity (Elders Benefits) $ Medicare of Medicaid $ Veterans Benefits (Including Burial Assistance) $ Alaska Permanent Fund Dividend (PFD) $ Unemployment Insurance Benefits (UIB) $ Worker s Compensation $ Native Corporation Dividends $ Checking Account $ Savings Account $ Donation $ Donation $ Other $ TOTAL RESOURCE INCOME $ READ BEFORE SIGNING I am applying for financial assistance on behalf of the deceased, who is in need, for burial assistance services. I, have received a copy of and have had explained to me, and understand the provisions of Federal Law governing fraud. I agree to supply information regarding resources and income and to notify the agency of any changes in my situation. Tribal Community Services is authorized to obtain information necessary to establish eligibility for assistance. I have read, or had explained to me, the provision of my protection under Paperwork reduction Act and the Privacy Act. Signature of Person Applying on Behalf of the Deceased

4 Copper River Native Association (AHTNA T AENE NENE ) Mile Richardson P.O. Box H. Copper Center, Alaska Phone (907) Fax (907) gjackson@crnative.org Website: AUTHORIZATION FOR RELEASE OF INFORMATION I,, hereby authorize the release of information requested by Copper River Native Association, Tribal Community Services Department, for, whom is my family member and is now deceased. The requested information shall be used solely in the administration of CRNA TCS programs. Information request include: Any and all financial information, Schooling; grades, transcripts, registration, scholastic achievement and financial information, meeting federal reporting requirements or for the purpose of criminal prosecution for violation of CRNA program requirements. Persons or organizations that may be contacted include, but are not limited to: the Alaska Department of Law, the Alaska Department of Fish & Game, the Alaska Department of Labor, the Alaska Department of Public Assistance, the Alaska Department of Revenue, the Alaska Department of Military Affairs, Alaska State Housing Authority, local governments, tax assessors, financial institutions, private corporations, landlords, employers, school authorities, and private individuals. This release of information shall be in effect while I am an applicant or recipient of the CRNA TCS P.L Program, and for any later investigations pertaining to my eligibility and receipt of the CRNA TCS P.L Program benefits. Information on Deceased: Name Social Security Number of Birth of Death A REPRODUCTION OF THIS RELEASE IS AS VALID AS THE ORIGINAL Applicant Signature Witness Signature if X signed

5 This portion of the Application is to be filled out by the Case Manager handling your case. Please do not fill anything in beyond this point. 1. Complete Application 2. Proof of Tribal Membership 3. Proof of Residency in Service Area 4. Proof of Insufficient Resources 5. Release of Information 6. Client Case Notes 7. Proof of BA Payment (Copies Attached) 8. Letter of Status Sent COMPLETED of Death: / / Application Received: / / Application Received By: Decision of Application: Approved Denied : / / Step 1. Burial Assistance Standard $2, Step 2. Subtract ALL Income/Donations Step 3. Maximum Burial Assistance Amount Step 4. Subtract Total Burial Cost. If burial amount exceeds the amount in step 3 use only the amount in step 3. Step 5. Remaining Funds. Money left over after paying the burial cost may be used to pay towards a Funeral Feast. Step 6. Funeral Feast. Amount paid out cannot exceed $ Step 7. Balance Step 8. Total Burial Assistance Paid. Subtract Step 7. from Step 3. Case Manager Signature: : / / Director Signature: : / / Case Name: : Case Documentation Case Manager Signature Supervisor Signature