EMAS - Burial Application IM-100 Jeffco 04

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The below verifications may be necessary to determine eligibility. Please submit the following information with your application.

Verifications for the deceased

Picture ID
Proof of Jefferson County residency
Birth Certificate, DD214, Passport, Naturalization Papers, or Permanent Legal Resident Card

Verifications for the deceased (and the deceased’s spouse)

All checking and savings accounts, showing the balance on the date of death
Current month of earned or unearned income verification (including any Social Security income, pensions, annuities, retirement income, or paystubs)
Personal needs account balance (if in a nursing home or hospice)
Copies of all life insurance policies or trusts (including the cash surrender value for each policy)
Verification of any real estate property or land
Copies of all vehicle registrations, including mileage

Copy of the provider’s proposed charges for funeral/burial/cremation

To be provided at time of application.

Failure to provide the above verifications may delay processing of benefits or result in the denial of your application for burial assistance.

Should a benefit be given, you will have 11 days from date of notification for our Department to receive a final copy of the invoice from the provider. Failure to provide a provider invoice within 11 days from date of benefit notification may result in the denial of your application for burial assistance.

Applications must be submitted within 30 days of the decedent’s date of death.

Jefferson County is prohibited from reimbursing for any and all services already paid.

Email your completed application to CAD - Supporting Document Submission or complete the application online at http://colorado.gov/PEAK. You may also submit your application via mail to Jefferson County Human Services, 900 Jefferson County Parkway, Golden, CO 80401.

Questions? Please call our team at 303-271-1388 or email burials@co.jefferson.co.us.

This form is an application for funeral, burial, and/or cremation death reimbursement benefits. The IM-100 form is used to determine eligibility for the State and county contribution toward the expenses of funeral, burial or cremation of a deceased recipient of public/medical assistance. The death reimbursement benefit must be applied for within thirty days of the date of death. Requests made after thirty days shall be evaluated by the county department and an extension may be given if good cause exists, not to exceed one (1) year from the date of death.

The form should be completed and signed by a relative, friend or other person who is interested in the disposition of the deceased. In the absence of such, the form may be completed by the county department of human/social services, which provided public/medical assistance to the recipient prior to death.

Although any interested party may complete the application on behalf of the decedent, they may not choose the manner of disposition. Colorado Revised Statutes, 26-2-129, gives certain relatives the right to choose the manner of disposition of a deceased recipient of public assistance if the decedent did NOT state their burial or cremation preference. Those relatives are defined as spouse, adult children, parents, and siblings. An appropriate family member should complete the required information to indicate a choice of disposition for the decedent.

The county department of human/social services must review the application for public assistance to determine if the decedent indicated a preference before honoring any family statement. If no family member(s) or other relative(s) are available or willing to make the choice, the county is authorized to choose the manner of disposition in accordance with current regulations.

Application for Funeral, Burial and/or Cremation Assistance

Please complete this form as thoroughly as possible. This form will be used to determine the State contribution toward the funeral, burial, and/or cremation expenses.

Name of Deceased: First and Last name Marital Status: Marital Status
Address at Time of Death:  Street Address      City/State   Zip code
Date of Death:   Date  CBMS #:  CBMS # State ID:State ID
Category of Assistance Received at the Time of Death:ANDOAPMedicaid Colorado Works
Name of Mortuary or Funeral Home:   Name of Mortuary or Funeral Home
Name of Applicant:   First and Last Name   Relationship to Deceased:   Relationship
Applicant Address:   Street Address   City/ State   Zip code

The resources owned by the deceased individual and/or the responsible party(s) may be considered in calculating the State contribution “Legally responsible person(s)” means a person who is the decedent’s spouse or the decedent’s parent if the decedent is an unemancipated minor who is under the age of eighteen; and bears legal responsibility for the charges associated with the decedent’s funeral, cremation, or burial expenses. Please list all resources and their value as of the date of death in the applicable area below. If additional space is needed, please provide information on a separate page.

Types of Resource

Rows	Owner (decedent or responsible party(s))	Value at time of death
Cash (including personal needs, bank accounts, burial funds)
Vehicles (use current value)
Property and other resources (describe)
Life insurance, funeral or burial plans

Burial Plot(s)

Rows	Owner name	Date of purchase	Cost at time of purchase
1.
2.
3.

*All payments from a decedent's estate, payments from legally responsible persons, and contributions from any other person persons who make a contribution to burial services shall be paid directly to the burial provider(s).

When completing and signing this application, I certify that the information supplied herein is accurate and complete to the best of my knowledge.

Signature of Applicant

Date:Date
Phone Number:Phone Number

Signature of Applicant

Social Security Number:Social Security Number Date:Date
Phone Number:Phone Number

Colorado Revised Statutes, 26-2-129, gives certain relatives (spouse, adult children, parents, siblings) the right to choose the manner of disposition of a deceased recipient of public assistance if the decedent did NOT state their burial or cremation preference. An appropriate family member should complete the statement below indicating a choice for the decedent. The county department of human/social services must review the application for public assistance to determine if the decedent indicated a preference before honoring any family statement.

I First Name Last Name , state that I am related to First Name Last Name who was a recipient of public assistance and/or Medicaid through theName of County County Department of Human/Social Services. My family relationship to the deceased is (select one)Husband Wife Father Mother Son Daughter Brother Sister Other: Describe Relationship

I hereby express the following preference for the disposition of the decedent’s body:

Describe additional details, if any:

Signature of Family Member

Date:Date

Address of Family Member:Street Address/ City/ State/ ZipPhone Number:Phone Number

The undersigned hereby affirms that s/he witnessed the signature by the recipient’s family member who appeared to be mentally competent to understand and exercise the choice of disposition.

Signature of Witness

Date:Date

Address of Witness:Street Address/ City/ State/ ZipPhone Number:Phone Number

Burial Assistance Application

IM-100 - APPLICATION FOR FUNERAL, BURIAL, AND/OR CREMATION ASSISTANCE

PURPOSE OF FORM:

GENERAL INFORMATION:

CHOICE OF DISPOSITION BY DECEDENT’S FAMILY MEMBER