Burial Claims Process Application Form – Fill Out and Use This PDF

Rev. 02/26/09

HUMAN RESOURCES ADMINISTRATION

OFFICE OF CONSTITUENT AND COMMUNITY AFFAIRS

BURIAL CLAIMS UNIT

25 Chapel Street, 6th Floor

BROOKLYN, NEW YORK 11201

Phone:(718)473-8310; Fax: (718) 473-8292

BURIAL CLAIMS APPLICATION PROCESS

Background:

The Human Resources Administration (HRA) will provide financial assistance to individuals in need of assistance to meet funeral expenses. These funds are available when an indigent resident of New York City dies who may have been in receipt of SSI, PA or no public benefits at all, without leaving funds to cover their burial expenses and there are no relatives or friends willing or able to pay the funeral expenses.

What can be covered:

•HRA will pay up to $900 towards a funeral which costs no more than $1,700. The cost of cremation or grave and grave opening charges are excluded, however, the cost of burying the cremains (ashes), after cremation is not excludable in calculating the $1,700 limitation. If the total funeral bill exceeds the amount of $1,700, HRA will make no payment.

•Any asset (whether or not previously assigned to HRA), that was available to the deceased or any amount that a legally responsible relative (spouse or parent of a minor child) may have on the date of death is deemed able to pay, and any amount paid or to be paid by any other source, will be subtracted from the $900 payment, if the claim is determined eligible for payment. Any assets or resources left by the decedent on the date of death will be subtracted from the $900, if the case is otherwise determined to be eligible.

To apply:

The individual who makes the funeral arrangements or his/her representative must file an application within 60 days from the date of death in person at our office located at 25 Chapel Street, 6th Floor in Brooklyn. That individual should bring any documentation to the initial interview and may submit the remainder of documentation needed by US Mail.

Required documentation:

1.A Burial Application Form completed and signed by the applicant.

2.One original certified copy of the Death Certificate (it will be returned to the applicant.)

3.A copy of the Funeral Contract also known as the Statement of Goods and Services Selected. The contract must be signed by the funeral director and by the party who made the funeral arrangements. The required sequential invoice number must appear on the document.

4.A copy of the cemetery or crematory bill, itemizing all charges.

5.Two original itemized funeral bills signed by the Funeral Director and notarized in the presence of a Notary Public. The funeral bills must be stamped “Paid-in-Full” if the charges have been paid.

6.Two original fully completed Funeral Director’s Affidavit Forms signed by the Funeral Director and notarized in the presence of a Notary Public, if there is money still owed to the funeral establishment.

7.Information and documentation regarding the decedent’s available assets/ income as of the date of death, and those of the applicant (if the applicant is a legally responsible relative) is required on each case.

8.The Agency may request any other documentation which can be necessary to make an eligibility determination based upon the particular facts and circumstances of each case.

M-860w (reverse)			Human Resources Administration
Rev. 1/16/09			Office of Constituent and Community Affairs
7) ESTATE
Did the deceased have a will?	Yes	No	Did the deceased leave an estate?	Yes	No

If yes, give details:

_______________________________________________________________________________

8)ASSETS

Did the deceased have any of the following assets at the time of death? If yes, give details.

Cash	Yes	No	Bank Accounts	Yes	No	Insurance Policies	Yes	No
Real Property	Yes	No	Union Benefits	Yes	No	Societies	Yes	No
Pension	Yes	No	Automobile	Yes	No	Other	Yes	No

9)HISTORY

Describe how the deceased supported him/herself: _____________________________________________________

Was the deceased employed at the time of death? Yes No

Name of employer_____________________________________

Address: ______________________________________________________________________________________

Type of work: ________________________________________
Did the deceased receive any assistance from the Family Independence or Social Security Administration?
Yes	No If yes, indicate category and case number:		PA	MA FS	SSI: ______________________
Was the deceased in receipt of Social Security?		Yes	Monthly Amount$_____			No

List any other information regarding the deceased, parents of a deceased minor child or deceased spouse’s assets, resources, income here.

The undersigned authorizes the Commissioner of the Human Resources Administration or his/her authorized representative to make all inquiries necessary in relation to this application and gives his/her full permission to have any or all of the information in this application verified.

Your signature__________________________________

Relation to Deceased: ____________________________

Signature of Applicant: _______________________________ Date: _________________________

STATE AND CITY OF NEW YORK

COUNTY OF___________________

Sworn to before me this__________day of _____________________, 20__

Notary Public or Commissioner of Deeds (Notarization is not required if applicant is receiving assistance)