3-HSS-26-033 - Indigent Burial - Appendix D - Assignment Form.docx

This is an Assignment Form document used by the Delaware Department of Health and Social Services, Division of Social Services, in connection with its indigent burial and cremation services program. The form serves as a legal instrument through which surviving spouses, next-of-kin, or legal representatives of deceased individuals assign all benefits, claims, demands, entitlements, and causes of action related to burial, cremation, and funeral expenses to the State of Delaware. The assignment is executed in consideration for the State's payment of burial or cremation and related funeral expenses for the decedent, as authorized under 29 Delaware Code Section 4711.

The Assignment Form requires completion of decedent information including name and date of birth, as well as former address. The document must be executed with signatures from the assignor (the surviving family member or legal representative), a witness, and a Department of Health and Social Services representative as assignee. Each signature section includes spaces for printed names, full addresses, and dates. The form contains placeholder sections for the street address where the assignment is executed and includes image placeholders, likely for official department seals or logos. This document is a standard administrative form used to facilitate the State's provision of burial and cremation services to indigent individuals by establishing legal assignment of any third-party claims or benefits that could offset the State's expenses.