Form Pa 118 – Fill Out and Use This PDF

NAME OF DECEASED

SOCIALSECURITYNO. OF DECEASED

CASE PAYMENTNAME

ADDRESS

AGE ATDEATH

DATE OF DEATH

DATE OF REQUEST

I.

REQUEST FOR BURIALAND/OR CREMATION PAYMENT: I request the Department of Public Welfare to pay the burial and/or cremation expenses of:

RELATIONSHIPTO DECEASED: I am a

RELATIVE

Representative of a fraternal society (deceased was a member) or of a charitable or religious organization:

State Relationship

(Give Name of Organization)

REQUEST

FRIEND

OTHER If this block is checked, this form must be accompanied by an “unfit certificate” from the Anatomical Board.

PAYMENTS TOWARD BURIALAND/OR CREMATION EXPENSES:

I will pay $

toward burial and/or cremation expenses. Payments by others will be as listed here:

MAKING

NAME

RELATIONSHIP

AMOUNT

IN BYPERSON

ASSETS OF THE DECEASED:

The following are all the assets available in the deceased’s estate (for example, insurance, savings, etc.)

DESCRIPTION OF ASSET

AMOUNT

TOBE FILLED

SIGNATURE OF PERSON REQUESTING PAYMENT FOR BURIALAND/OR CREMATION: I certify that to the best of my acknowledge and belief the statements

above are true and correct and there are no other means available. If additional facts become known to me. I will advise the County Assistance Office at once.

DATE SIGNED

SIGNATURE

WITNESS

ADDRESS

II.

The CAO determined the availability of resources that may reduce DPW payment as noted below. (Check one block apposite each item)

REDUCE

REDUCE

DPW

NONE

DPW

NONE

PAYMENT

FOUND

DESCRIPTION

PAYMENT

FOUND

DESCRIPTION

DIRECTOR

A.

Life insurance or burial benefits.

F.

Worker’s Compensation.

B.

Cash on hand in decedent’s estate and other

G.

Burial Reserve.

personal property.

EXECUTIVE

C.

Lump-sum death payment - Railroad Retirement

or OASDI.

YES

NO

D.

Contributions from any person(s) or agencies.

H.

Deceased was a UMWAmember for

E.

Award from accidental death (not Worker’s

whom funeral expenses or burial

OF

benefits are available.

Compensation).

I.

Deceased was a veteran.

CERTIFICATION

AA-21 for deceased railroad employee was not forwarded to Division of Assistance payments, because:

The surviving spouse has received the lump-sum death benefit.

The deceased never had railroad employment.

I certify that on the date DPW was requested to pay for the burial and/or cremation of the decedent named above, the Department’s regulations were met for payment

of the burial and/or cremation of said decedent, and that the County Assistance Office staff so indicated to the funeral director. I have reviewed the invoice on the reverse of

this form and certify that to the best of my knowledge and belief all regulations have been complied with.

SIGNATURE OF EXECUTIVE DIRECTOR OR DELEGATE

DATE

BURIALREQUEST - INVOICE

COMMONWEALTH OF PENNSYLVANIA - DEPARTMENTOF PUBLIC WELFARE

PA118 11/07

SIGNATURE OF FUNERALDIRECTOR

DATE