Pinellas_County_Application_for_Indigent_Cremation_Watermarked.pdf

PINELLAS COUNTY HUMAN SERVICES APPLICATION FOR

INDIGENT CREMATION PROGRAM

Application Date: ____________________________ Obituary Date: _______________________

Indigent Cremation Application - Page 1 of 3

Deceased Information

Full Legal Name of Deceased: ________________________________________________________________

Legal Address: __________________________________________________________ Apt # _____________

City_____________________________________ State _____________ Zip________________

Phone # (________) _________________________________________

Residence Status: Own Home Rent How Long at Address? _____________________

Social Security #: ______________________________________________ Race: ______________________

Date of Birth: ________________________ Date of Death: _______________________ Age: _________

Marital Status: Never Married Married Widowed Divorced

Occupation (at time of retirement or death): __________________________ Kind of Business: _____________________

Minor Children?: Yes No Social Security Death Benefit: _________________________

Applicant/Next of Kin Information

Name: ___________________________________________________________________________________

Relationship to Deceased: ____________________________ Date of Birth: ___________________________

Social Security #: ___________________________________ DL# ___________________________________

State Issued: _______________________________________ Expiration Date: _________________________

Legal Address: _____________________________________________________________________________

City______________________________________ State ________________ Zip____________

Home Phone ( _______ ) ________________________ Work Phone ( _______ ) ____________________

Other / Mobile Phone ( _______ ) ________________________ Best Time to Contact? ___________________

Residence Status: Own Home Rent How Long at Address? _______________________

Type of Indigent Services Requested The following funeral options are offered by Vendor paid for by Pinellas County Human Services as authorized by the Board of County Commissioners under the Indigent Cremation Program as outlined in the Florida Statutes. These services are offered for sole benefit of those individuals (deceased and / or applicant) who currently receive state/county assistance or live at or below the poverty level as outlined in the Federal guidelines. If you do not meet these criteria, please consult with the funeral director about other options that are available to you and your family during your time of loss.

Option A - Direct Cremation Only – This service is offered at Pinellas County expense. No services, rites, ceremonies or v iewings/visitations are permitted with this option. All merchandise and services are limited only to direct cremation as authorized by county contract. Cremated remains will be available after 14 business days following all approvals. Applicant's Initials_________

Option B - Anatomical Donation – This service is available to both unclaimed and claimed human remains. All anatomical d onations are subject to approval and acceptance by the Anatomical Board of the State of Florida located in Gainesville, FL. If accepted, additional paperwork and authorizations will be required by the anatomical board. If deceased’s remains are not acceptable to the Anatomical Board, then the funeral provider is authorized to perform option A stated above. Applicant’s Initials_________

Burial at National Cemetery – This service is only available at Pinellas County expense for unclaimed honorably discharged veterans. No rites, services or ceremonies are available or authorized with this option. Applicant’s Initials_________

Vendor

SAM

PLE

Name of Deceased:___________________________________________

Indigent Cremation Application - Page 2 of 3

Death Information

Place of Death: Deceased Residence Hospital Nursing Home / Convalescent Care

Hospice Facility VA Hospital Other_________________

If Nursing Home/Convalescent Center:

Facility Name: _________________________________________ Contact Name: ______________________

Address: ______________________________________________ Phone # ___________________________

Admit Date: _______________ Patient Trust Balance: ______________ Medicaid Recipient? YES NO

Beneficiary: ___________________________________________ Phone # ___________________________

Medical Examiner / Police Report # ________________________ Police Department: __________________

Property & Evidence: ______________________________________________________________________

Deceased’s Financial Statement

INCOME

List all sources of income for the deceased at time of his/her death and monthly benefit amount:

Social Security $ ______________ Veteran Benefits $______________ Employment $ _______________

Retirement Benefits $ __________________ Other:_______________________ $___________________

Representative Payee / Attorney _______________________________ Direct Deposit _________________

ASSETS

Bank Accounts: Bank Name ______________________________ Branch _____________________

Checking # ______________________________ Current Balance $ ____________

Savings # _______________________________ Current Balance $ ____________

Certificate of Deposit #_____________________ Current Balance $ ____________

Brokerage Accounts: Name of Institution ________________________ Phone: _____________________

Financial Advisor_______________________________________________________

Stocks $ _____________ Bonds $ __________ Annuity $ _______________

IRA $ _______________ Mutual Funds $ _______________ Other $ __________

Real Estate Owned:

Address Type Market Value Current Mortgage Mortgagee

Insurance:

Insured Company Name Beneficiary Face Amount Cash Value

Does the deceased have burial insurance or a prepaid funeral account? YES NO Provider? __________________________

Does the deceased have a will? YES NO Does the deceased have a trust? YES NO

Name of Attorney/PR ________________________________________ Phone #_____________________

Probate: ______________________________ Benefits Available: ______________________________

Other: __________________________________________________________________________________

Veteran Status

Branch of Service _______________ Date of Enlistment: ____________ Date of Discharge: ____________

Discharge Status: Honorable Other ______________________

Service / Serial #_______________________ Receiving VA Benefits: YES NO – Type: ____________

Please provide a copy of the DD-214 in order to expedite verification of eligibility / status.

Name of Deceased:___________________________________________

The following additional documentation may be required by the Vendor and Pinellas County Human Services in order to determine eligibility for the Indigent Cremation Services Program.

Deceased: Applicant:

Last 3 years of Federal Tax Returns Last 3 years of Federal Tax Returns

Current W-2 statements if employed Current W-2 statements if employed

Copies of all bank account statements Copies of all bank account statements

Copies of all investment account statements Copies of all investment account statements

Copy of Veteran Discharge (DD214) papers Contact information for verification of income

Contact Information for verification of income

The undersigned hereby authorizes Vendor, in partnership with Pinellas County Human Services, to verify, share, transmit, and/or use all information provided by the applicant about the deceased and/or the applicant themselves, necessary to approve or deny services through the Indigent Cremation Services Program. This verification may include, but is not limited to, personal references, records verification, review of documents provided, etc. Applicant's Initials____________

Under the penalty of perjury, the undersigned hereby certifies that the information given on this form is true and correct. The undersigned further certifies that he/she does not have the financial resources to pay for the services requested for the deceased, nor can the undersigned obtain the necessary financing to pay for these expenses. Applicant's Initials____________

The undersigned is obligated for the entire balance due to the funeral establishment until such time as Pinellas County Human Services can determine eligibility. Should the application be approved for county indigent assistance, the funeral provider will release the applicant from all liability and payment for services rendered will be paid by Pinellas County Human Services under its contractual relationship with the provider. If the application is denied, the entire funeral balance becomes due and payable immediately by the applicant before services are rendered by the funeral establishment.

Signed this ___ day of ___________, 20______

Applicant's Signature ____________________________________

Indigent Cremation Application - Page 3 of 3

Applicant's Financial Statement

INCOME

List all sources of income for the applicant as well as monthly benefit amount:

Social Security $ ______________ Veteran Benefits $______________ Employment $ _______________

Retirement Benefits $ __________________ Other:_______________________ $___________________

ASSETS

Bank Accounts: Bank Name ______________________________ Branch _____________________

Checking # ______________________________ Current Balance $ ____________

Savings # _______________________________ Current Balance $ ____________

Certificate of Deposit #_____________________ Current Balance $ ____________

Brokerage Accounts: Name of Institution ________________________ Phone: _____________________

Financial Advisor_______________________________________________________

Stocks $ _____________ Bonds $ __________ Annuity $ _______________

IRA $ _______________ Mutual Funds $ _______________ Other $ __________

Real Estate Owned:

Address Type Market Value Current Mortgage Mortgagee

References: (please provide 3 personal references including contact information)

Name Address Phone Relationship