Dhs 1163 Form PDF Details

When facing the passing of a loved one, the financial aspects of funeral arrangements can add an additional layer of stress during an already difficult time. The State of Hawaii's Med-QUEST Division, through the Department of Human Services, offers a form of relief through the DHS 1163 Form, also known as the Death Payments Program Application. This form is designed to assist residents in applying for financial support to cover funeral expenses under specific conditions. It requires information about the deceased, including their name, Social Security number, veteran status, and the date of death. It also asks for the applicant's details, such as their relationship to the deceased, contact information, and whether other funeral benefits are available. The form importantly clarifies that if there are full funeral benefits available from other sources, or if the decedent's estate or the Veteran’s Administration (VA) can provide support, the Department of Human Services may recover payments made. Applicants must also acknowledge the potential legal repercussions of providing false information. Furthermore, the form outlines the process for the department's use only, detailing how the application will be evaluated and the outcome documented. This introduction serves to pave the path for understanding the application process and the associated responsibilities when seeking financial assistance for funeral expenses through the DHS 1163 form.

QuestionAnswer
Form NameDhs 1163 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdhs 1163 form, dhs 1163 online, dhs 1157 fillable, dhs 1163

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STATE OF HAWAII

Med-QUEST Division

Department of Human Services

 

DEATH PAYMENTS PROGRAM APPLICATION

(Please attach a copy of the death certification if one is available)

I.Decedent's information:

Decedent's Name: _____________________________________________________ Sex: _______

Social Security No.: ___________________________________

Date of Birth: _________________

Veteran – VA File Number: _____________________________

Date of Death: ________ _______

II.Applicant's information:

Applicant's Name: __________________________________ Relationship to Decedent: ___________

Social Security No: _________________ Home/Cell Phone: ___________ Work Phone: _________

Applicant’s Mailing Address: ____________________________________________________________

III. Are any full funeral benefits available to the decedent such as pre-paid funeral or burial plans,

insurance plans, associations, and clubs? (Full funeral benefits mean funeral and/or burial services that provide a complete and dignified disposal of the decedent.)

Yes _______

No _______

IV. Has anyone received or expect to receive, the lump-sum death payment benefit from Social Security for the decedent?

Yes _______

No _______

V.I understand that the Department of Human Services may recover for payments made by the Death Payments Program from the Veteran’s Administration (VA) or the estate of the decedent.

I certify the information I have provided on this application is true to the best of my knowledge. If I intentionally make false statements on this application, I may be prosecuted under Hawaii Revised Statutes §346-43.5 or other criminal laws.

I further certify that the Death Payments Program payment shall be made to me and sent to my address as listed under item II above.

___________________________________________________

____________________________

(Applicant's Signature)

(Date)

.................................................................................................................................................................................................................................................................................

FOR OFFICIAL USE ONLY

VI. Disposition:

 

 

 

Application is:

_____ Approved

_____ Denied

_____ Discontinued

Explanation/reason for disposition: _______________________________________________________________________

_________________________________

___________________________________

__________________

(Printed Name of Eligibility Worker)

(Authorized Eligibility Worker’s Signature)

(Date)

DHS 1163 (Rev. 12/11)

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This form will require you to provide specific details; to guarantee accuracy and reliability, you should take into account the next suggestions:

1. The dhs 1157 fillable necessitates certain details to be typed in. Be sure that the next fields are finalized:

Writing segment 1 of form dhs 1163

2. Once the previous section is filled out, go to type in the applicable details in all these - Security for the decedent, Yes No, I understand that the Department, Applicants Signature, Date, FOR OFFICIAL USE ONLY, VI Disposition, Application is Approved Denied, Explanationreason for disposition, Printed Name of Eligibility Worker, Authorized Eligibility Workers, and Date.

Part no. 2 of filling out form dhs 1163

It is possible to make errors while filling out your VI Disposition, consequently you'll want to reread it prior to when you submit it.

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