HennepinCountyBurialAssistanceApplication

Pleaseacceptourcondolencesonyourrecentloss.Werealizethisisaverydifficulttimeandwe hopeto doeverythingpossibleto make this processgo smoothlyforyou.

TheenclosedApplicationforBurialAssistancemustbecompletedandreturnedtoHennepinCountywithin14daysofnotificationofthenextofkin.Theapplicationshouldbecompletedbytheclosestlivingrelativeorlegalrepresentative.Undercurrent policythetotalamountofburialexpensescannotexceed$4,400.HennepinCountyallowsforafamilycontributionof$1,400towardthecostoftheburial.Ifthetotalcostoftheburial/funeralexpensesexceeds$4,400 Hennepin County cannotapproveyourapplication.PleaserefertotheBurialAssistancebrochureforinformationonwhatexpensesareallowable.Themaximumamount of burialassistanceHennepinCountymaycontributeis$3,000.HennepinCountydoesnot reimburseforpaymentsalreadymade.

Youmaybeaskedtoprovideverificationoftheincomeandassetsofthedecedent,spouseand/orotherresponsiblerelatives.Verificationmustbereceivedwithin30daysofthe date ofapplicationand must be verifiedasofthe date ofdeath.

Youmayreturnyourcompleted,signedapplicationby:

1)FAXING- Faxcompletedapplications to 612-632-8493

2)MAILING-Mailcompletedapplication to:

HennepinCountyHumanServicesDepartmentBurialAssistance,MailCode 638

1201 E. Lake StreetMinneapolis,MN 55407

IN PERSON INTERVIEW–In person interviewsareavailable byappointmentonlyandare not required.

If you have questionsabout the processorwouldliketo requestanappointment, pleasecontact a BurialAssistance Specialist

at 612-348-7984.

Hennepin CountyApplicationfor BurialAssistance

Informationaboutthe deceasedperson:

1.Name ofDeceased:

FirstMiddleLast

2.Date ofBirth:Date of Death:

3.SocialSecurityNumber:

4.Lastknownaddress:

CityStateZip

5.MaritalStatus(CircleOne):SingleMarriedSeparatedDivorcedWidowed

Ifmarried,name ofspouse:

6.Was the deceased orspouse of the deceased aVeteran?YesNoUnknownIfyes,complete thefollowingif known:

Branch:_Type of Discharge:Claim #:

7.Did this person die asa result ofacrime committed againstthem? YesNo

8.Was the deceased amemberofa Native AmericanTribe?YesNoUnknown

9.Was the deceased on anytypeofPublic Assistance?YesNoUnknownIfyes,CaseNumber:

10.Did the deceased havea prepaid burial orcemeterylot prior to death?YesNoUnknown

11.Mortuaryhandlingfuneral arrangements:

Phone#:

12.Cemeterywhere the deceased willbe/isburied:

Phone#:

Assets

Thissectionpertains to assets andavailableresources.Wemust have informationaboutassets ofthedecedent/spouse and orotherresponsible relatives.

Yes / No / Owner / Value at dateofdeath / FinancialInstitutionandaccount # ifapplicable
Cash
Bank Accounts
Stock Bonds, CDs,
Trust Fund
RealProperty
HomesteadedY/N
Vehicles
Life Insurance
Annuities
Livestock, FarmEquipment,Machinery
Other property,includingboats,Recreationalvehicles, vacationor rentalproperty

Allassets willneedto be verified as ofthe individual’sdate of death. If the deceasedwas onpublic assistance in HennepinCounty,wemay beable to assistyou inobtainingthose verifications. Ifthere is not adequate space to listall assets in acategory pleaseliston a separate attachment.

HouseholdIncome

In orderto determineeligibilityfor burial assistance, information is neededon the incomeofthedecedent,spouseand/orotherresponsiblerelatives.Ifyouarenotthespouseorotherresponsiblerelativepleasecompletethissectionasitpertainstothedecedentonly.

Decedent’sIncome Source: Ifthe decedent was employed, Employer contact information:

Name ofspouseor otherresponsible relative

SSN:

DOB:

Number of dependents: _

(PleasenotethatadependentisaspousewithoutanincomeoftheirownORachildunder theageof18 whowas amemberofthe decedent’shousehold)

Ifyou arethespouseorsurvivingresponsible relative,please completethe following:Employer: Phone Number:

*Please provide copies ofcheckstubsfor the last30 days.

Ifyouarenotemployedpleaseprovideastatement/explanationofhowyoumeetyourmonthlylivingexpenses.Pleaseincludeinformationonothersourcesofincomesuchassocialsecurity,pension,rentalincome,child support, etc.

Source ofIncomeMonthlyAmt

How much doyoupayformonthlymedicalexpenses not coveredbyinsurance?

Doyoupaycourt ordered support? Ifyes, monthlyamount?

Medicalinsurancepayments,uncoveredmedicalexpensesandchildsupportareconsideredallowable deductions fromyour income.

RIGHTSAND RESPONSIBILITIES

Please read thefollowing statements. Ifyou do not understand a statement,pleaseaskthat it be explained toyou.Sign belowto indicate thatyou have read andunderstood the statements:

  • Ideclare, underanyapplicable penalties of criminal liabilityprovided in thelaws ofthe State ofMinnesota, whichallstatementscontained in thisapplication, to the best of myknowledge andbelief,are true, correctandcomplete.
  • Iunderstandthat ifIknowinglyprovidefalse information on this application,Imaybe subject to prosecution for fraudand legal actionmaybe initiated torecover anyburial expensespaidbyHennepinCounty.
  • I agree to notifyHennepin CountyFront Door BusinessPartners,BurialAssistance Unit ifanyresources not listed in this applicationare locatedafterIhave completed this form. Iunderstandthatallresourcesofthe deceasedmust first be used to defrayanyburialexpenses authorized or paidfor byHennepinCounty.
  • I allow Hennepin CountyBurialAssistance staff toexchange informationwiththe funeraldirector to determine myeligibilityforBurialAssistance.Ialsoallow Hennepin CountyBurialAssistance staff toobtaininformationabouttheincome and assets ofthe deceased from their public assistance caseifapplicable.

SignatureDate:

Informationabout personcompletingapplication:(pleaseprint)

Name: Relationship to Deceased: Address: City State Zip Phone numbers:

Home:Cell Work Fax

Ifpersonfillingout theform is notLegal Next of Kinplease list legal next ofkin below:

Name:

Phone#:

Burial AssistanceApplication 01/01/175