Funeral Claim Form PDF Details

Funerals can be expensive, and many families find themselves facing a large bill after the death of a loved one. In some cases, the funeral home may ask for payment in full before releasing the deceased's body. If you're unable to afford to pay for the funeral, you may be able to apply for financial assistance through your state or local government. Each state has its own rules and regulations governing funeral assistance, so it's important to contact your local government office for more information. Typically, you'll need to complete a funeral claim form and provide proof of income and expenses. You may also be asked to provide documentation of the death certificate and burial arrangements.

QuestionAnswer
Form NameFuneral Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesillinois funeral claim, funeral claim, funeral reimbursement, burial claim

Form Preview Example

State of Illinois

Department of Human Services

FUNERAL AND BURIAL REIMBURSEMENT CLAIM

4(3 YEARS)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

See instructions on reverse side.

CLAIMANT IDENTIFICATION

 

 

 

 

 

COMPLETE

Print or Type all entries except signatures

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. SSN:

 

 

 

 

 

 

 

2. Type:

 

 

ALL ITEMS

5. Submit 3 copies to local office located at:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter "NA" if

 

 

 

 

 

 

 

 

 

3. Name,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

an item is not

 

 

 

 

 

 

 

 

 

 

 

Address,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

applicable

 

 

 

 

 

 

 

 

 

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Relationship to Decedent:

 

 

 

 

 

 

 

 

 

 

 

6. Attention:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLIENT IDENTIFICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Case Name:

 

 

 

 

 

 

 

 

8. Case Number:

 

 

 

 

9. Date of Death:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. Decedent's Name:

 

 

 

 

 

 

 

 

11. Social Security Number:

 

 

12. DOB:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Funeral Home:

 

 

 

 

 

 

 

 

 

 

 

14. Cemetery:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHARGES

 

 

 

 

 

 

DOCUMENT

ASSETS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. Funeral Cost:

 

 

 

 

 

 

AMOUNTS SHOWN

19. Responsible Relative Payments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attach copies of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. Burial Cost:

 

 

 

 

 

 

 

20. Estate Fund:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

contracts, purchase records,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17. Total Cost:

 

 

 

 

 

 

 

and receipts.

21. Death Benefits:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Show amounts paid, the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18.Total Cost Paid:

 

 

 

 

 

 

22. Total Amount of Resources:

 

 

 

 

 

 

 

 

payor and the payee.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23. MAXIMUM REIMBURSEMENT may not

 

 

 

 

 

 

 

24. Maximum Reimbursement:

 

 

exceed this standard, the cost of service or the

 

 

 

 

 

 

 

 

 

 

REIMBURSEMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

total amound paid,WHICH EVER IS LESS.

 

 

 

 

 

 

 

25. Total Amount of Resources:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Funeral

Burial

Total Effective Date

 

 

Anatomical Gifts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$1073

$537

 

$1610

07/01/06

 

Limited to $142.00

26. Allowable Reimbursement:

 

 

 

 

 

 

 

 

 

 

$1103

$552

 

$1655

07/01/07

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27. LOCAL OFFICE CLAIM REVIEW

 

 

 

 

 

28. This is to certify that the above information is true, accurate,

This is to certify that this claim is accurate and complete,

 

 

and complete; that I have assumed responsibility for payment in

that it complies with the Rules and Regulations, and that

 

 

full of the above identified decedent's funeral and burial

PAYMENT is hereby Approved.

 

 

 

 

 

expenses. I understand that this claim may be amended to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

comply with the Rules and Regulations of the Department of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Local Office Signature:

 

 

 

 

 

 

 

 

 

 

 

Human Services. I further understand that payment is made

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

from State Funds and falsification of a material fact may lead to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

appropriate legal action.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Central Ofc. Signature:

 

 

 

 

 

 

 

 

Claimant Signature:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CO Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Only:

 

 

 

 

 

 

 

 

 

 

 

 

 

Claimant Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IL 444-0094 (R-06-07)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 1 of 2

State of Illinois

Department of Human Services

FUNERAL AND BURIAL REIMBURSEMENT CLAIM 4(3 YEARS)

INSTRUCTIONS FOR COMPLETION OF IL 444-0094

(Review form for completion to eliminate delay in processing)

This form is used to reimburse the person who has assumed full responsibility for the funeral and burial expense of a deceased Department of Human Services recipient. When two or more persons have been party to the arrangements, one must be designated to file the claim for reimbursement since only one claim will be accepted.

The following identified persons will NOT be reimbursed.

1.A beneficiary of the decedent's life insurance, unless insurance proceeds are less than the appropriate reimbursement standard.

2.The decedent's spouse.

3.A parent of a decedent under 18 years of age.

Time Limitations

1.A written explanation must accompany claims not submitted in 30 days of death.

2.Claims not submitted in 180 days of death will be denied.

3.Claims returned to claimants will be denied if not resubmitted in 90 days.

INSTRUCTIONS FOR COMPLETION OF ITEMS

Items

1-4. Enter claimant information. Leave item 2 blank.

5-6. Enter information regarding the local DHS Office.

7-12. Enter client information.

13-14. Enter funeral home and cemetery names.

15-17. Enter total funeral cost and burial costs. Item 17 will be calculated based on entries for items 15 and 16.

18.Enter actual total cost paid by claimant for funeral and burial.

19-22. Enter amounts to offset funeral costs from listed sources. Item 22 will be calculated.

24.Enter total allowable reimbursement amount as listed in item 23.

25.Amount will be repeated from item 22 above.

26.Allowable reimbursement will be calculated.

27.Local Office review and certification block. Must be signed and dated by appropriate local office staff.

28.Claimant certification block. Claimant must sign, date and enter a valid telephone number.

ATTACH SEPARATE SHEET TO EXPLAIN UNUSUAL CIRCUMSTANCES

Distribution - Original and one copy to Funeral and Burial Unit, Bureau of Local Office Transactions and Support Service Claimant - copy

Local Office - copy

IL 444-0094 (R-06-07)

Page 2 of 2

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