Application for Funeral, Burial and / or Cremation Assistance V2

Application for Funeral, Burial and / or Cremation Assistance

IM-100 (8/26)
PURPOSE OF FORM:

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.

GENERAL INFORMATION:

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 NameLast Name
Marital Status
Home Address at Time of Death

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Date of Death

MonthDayYear
Social Security Number
Date of Birth

MonthDayYear
Name of Mortuary or Funeral Home or Cemetery
Name of Applicant

First NameLast Name
Relationship to Deceased
Other Relationship Description
Applicant Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant Email Address

Confirmation Emailexample@example.com
Applicant Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.

Type of Resource

Rows	Description of Resource(s)	Owner (decedent or responsible party(s))	Value at time of death
Cash (including personal needs, bank accounts, monetary resources)
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
1st Burial Plot
2nd Burial Plot
3rd Burial Plot

*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 1st Applicant
Date

MonthDayYear
Phone Number of 1st Applicant
Please enter a valid phone number.Format: (000) 000-0000.
Signature of 2nd Applicant
Date

MonthDayYear
Phone Number of 2nd Applicant
Please enter a valid phone number.Format: (000) 000-0000.

Application for Funeral, Burial and / or Cremation Assistance

Application for Funeral, Burial and / or Cremation Assistance

Choice of Disposition by Decedent's Family Member