Indigent_Funeral_Referral_(Pinellas_County)_watermarked_.pdf
PDF 933 KB Posted
- Attached to
- Indigent Burial and Cremation Services
- Solicitation number
- 26-0292-RFP
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This is an Indigent Cremation Referral Form for Pinellas County, Florida, designed to collect comprehensive information about deceased individuals requiring indigent burial or cremation services. The form captures essential data including the deceased's personal information (name, Social Security number, date of birth and death, sex, race, and cause of death), residential address history, veteran status, Social Security death benefit eligibility, and next-of-kin contact details. The form also documents family consent preferences regarding burial versus cremation, body condition assessment, and autopsy status. The document is submitted to Pinellas County at 440 Court Street, 2nd Floor, Clearwater, Florida 33756, with contact available at (727) 464-3000. This referral form serves as the intake document for the county's indigent burial and cremation services procurement (RFP 26-0292-RFP), which anticipates approximately 1,060 calls for service annually comprising 720 claimed and unclaimed human remains (650 adults, 50 veterans, and 20 stillborn or infant cases).
The related solicitation requires qualified funeral service providers to submit proposals by April 14, 2026, at 3:00 PM via the OpenGov procurement website, with questions due by March 31, 2026, at 12:00 PM. The five-year contract awards compensation based on a tiered evaluation: qualifications (35 percent), scope of work (25 percent), deliverables (25 percent), and compensation (15 percent). Qualified bidders must hold a current Florida funeral director license, maintain an FDEP-certified incinerator, provide refrigerated storage for up to 100 concurrent bodies, and demonstrate minimum five years of governmental indigent services experience. Pricing is capped at $30,000 annually with fixed rates regardless of actual case volumes, and the annual funding does not exceed $550,000. Required insurance includes $1,000,000 commercial general liability, $1,000,000 professional liability, and workers' compensation coverage. Bidders must submit Foreign Countries of Concern, Human Trafficking, and Common Carrier attestations, along with a HIPAA Business Associate Agreement. No set-asides, incumbent information, or scheduled site visits are referenced in the solicitation.
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Text version
Indigent Cremation Referral
Information of Deceased:
Name: _________________________________________ Social Security Number: ___________________
Date of Birth: _______________ Date of Death: _______________ Sex: M ___ F ___ Race: ___________
Cause of Death: _____________________________________________ Date of Obituary: ______________
Marital Status: Single ___ Divorced ___ Widow(er) ___ Married ___ Name of Spouse: __________________
Address at Time of Death: ________________________________________________________________________ (Street)
(City) (State) (Zip Code) (Phone Number)
Previous Address (if applicable): _____________________________________________________________ (Street)
(City) (State) (Zip Code) (Phone Number)
Veteran: Yes ___ No ___ Eligible for Social Security Death Benefit: Yes ___ No ___
Contact Person for Deceased – Relative, Friend, Guardian (required for a Minor Parent):
Name: __________________________________________ Social Security Number: _________________
Relationship to Deceased: _____________________________
Address: _________________________________________________________________________________ (Street) (City, State) (Phone Number)
Family Consent / Anatomical Board: Yes ___ No ___ Burial ___ Cremation ___
Body Condition: Good ___ Infectious ___ Deteriorated ___ Autopsy ___
Additional Information: _____________________________________________________________________
440 Court Street, 2nd Floor, Clearwater, Florida 33756 Ph: (727) 464-3000
Vendor
SAMPLE
Sara.Hadden Cross-Out
Brea Templeton Cross-Out
| Date of Obituary: |
| Name of Spouse: |
| Previous Address if applicable 1: |
| Previous Address if applicable 2: |
| Zip Code_2: |
| Phone Number_2: |
| Additional Information 1: |
| Additional Information 2: |
| Additional Information 3: |
| Check Box5: Off |
| Check Box6: Off |
| Check Box7: Off |
| Check Box8: Off |
| Check Box9: Off |
| Check Box10: Off |
| Check Box11: Off |
| Check Box12: Off |
| Check Box13: Off |
| Check Box14: Off |
| Check Box15: Off |
| Check Box16: Off |
| Check Box17: Off |
| Check Box18: Off |
| dec_FullNameWSuffix: |
| dec_DOB_MMDDYYYY_DropLeadZeros: |
| dec_GenderFemale_X: Off |
| dec_GenderMale_X: Off |
| dec_SSN_WithDashes: |
| decdeath_DOD_MMDDYYYY_DropLeadZeros: |
| dec_Race: |
| dec_Addr1Addr2AptSuite: |
| dec_City: |
| dec_Zip: |
| dec_Phone: |
| causes_CauseA: |
| dec_MilitaryYes_X: Off |
| dec_MilitaryNo_X: Off |
| nok_CompleteName1: |
| nok_SSN1: -- |
| nok_RelationshipToDeceased1: |
| nok_Address1: |
| nok_CSZ1: |
| nok_Phone1: |
File details come from the government source that posted it. Updated .