Burial Assistance Application

Copper River Native Association

(

)

Mile 111.5 Richardson Highway

P.O. Box H

.

Fax (907) 822-8800

E-mail: gjackson@crnative.org Website: www.crnative.org

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 2103.7 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 Date of Birth: / / Date of Death: Deceased’s Physical Address:

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: Relationship to Deceased:

Person applying on behalf of deceased

Mailing Address:

Home Phone: Message Phone: Work Phone:

What arrangements have been made for the burial?

Name of Mortuary:

Address:

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:

Address:

Building Material Cost: $

(Attach Receipts)

Invoice Needed – Cost not to exceed amount of casket – fence cost is not allowable.

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 $400.00 and will only be allowed if there is money left over after paying the burial cost.

Vendor Name:

Phone:

Fax:

Address:

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 Date

Copper River Native As sociation

(

)

Mile 111.5 Richardson

P.O. Box H

.

Fax (907) 822-8800

E-mail: gjackson@crnative.org Website: www.crnative.org

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. 102-477 Program, and for any later investigations pertaining to my eligibility and receipt of the CRNA TCS P.L. 102-477 Program benefits.

Information on Deceased:

Name Social Security Number

Date of Birth Date of Death

A REPRODUCTION OF THIS RELEASE IS AS VALID AS THE ORIGINAL

Applicant Signature Witness Signature if “X” signed

Printed Name Printed Name

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.

COMPLETED

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

Date of Death: / / Date Application Received: / / Application Received By:

Decision of Application: Approved Denied Date: / /

Step 1. Burial Assistance Standard

_$2,500.00

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 $400.00

Step 7. Balance

Step 8. Total Burial Assistance Paid. Subtract Step 7. from Step 3.

Case Manager Signature: Date: / /

Director Signature: Date: / /

Case Documentation

Case Name: Date:

Case Manager Signature Supervisor Signature