Free 35937.FH11 - Indiana

APPLICATION AND CLAIM FOR FUNDS TO DEFRAY BURIAL COSTS MEDICAID AGED, BLIND AND DISABLED RECIPIENTS
State Form 35937 (R3 / 3-04) / FM 0033 Approved by the State Board of Accounts, 2004

INSTRUCTIONS: Claimant shall complete three (3) copies, send two (2) to Local Office of Family and Children, and keep one (1). If claims for both funeral and cemetery expenses are made by one (1) person, only one (1) set of FM 0033 is to be completed. If this is done, the funeral director shall attach a receipted bill showing the amount of cemetery expenses paid by him. If the funeral claim and cemetery claim are made by two (2) different persons, each shall complete FM 0033 as it pertains to his claim. The Local Office of Family and Children will enter on the reverse side the amount of resources available to meet this claim and after approval the Director certifies that the claim is in proper form, enters the amount approved for payment, signs it, files the original with Financial Management at Central Office. RECIPIENT INFORMATION
Name of recipient (last, first, middle) Last residence (number and street, city, state, ZIP code): Check appropriate box ICES case number Date of death (month, day, year)

MA-A 1 2

MA-B 3

MA-D
County number Name of county

ITEMIZED COST OF BURIAL FUNERAL DIRECTOR'S EXPENSES
(includes cremation)

CEMETERY EXPENSES Burial plot: Opening & closing: Wooden box / Concrete slab: Lowering device: Tent or artifical grass: Vault: Other: Specify and attach receipt

Preparation of body: Clothing: Casket: Funeral services: Transportation: Professional services:

Other: Specify and attach SECTION III B receipt Total cost of Funeral Directors expenses: $
CEMETERY

Total cost of cemetery expenses: CONTRIBUTIONS AND RESOURCES

$
FUNERAL CEMETERY

FUNERAL

Insurance Bank balance Veteran benefit Friends or family Total to Funeral Director and / or Cemetery Authority: TOTAL CONTRIBUTIONS AND RESOURCES:
Name of contributor (attach additional pages, if necessary)

Social Security Lump sum death benefit Other: Specify

$ $
Address (number and street, city, state, ZIP code)

$

AMOUNT CLAIMED FROM OFFICE OF DIVISION OF FAMILY AND CHILDREN
Name of Funeral Home or Cemetery Address (number and street) City State ZIP code Claim for Funeral Director's Expenses Claim for Cemetery Expenses

$ $ $
Total

PROVIDER CERTIFICATION Pursuant to the provisions of IC 5-11-10-1 (e), I certify that the foregoing account is true and correct, that the amount claimed (___________________) is legally due, after allowing all just credits, and that no part of the amount has been paid.
Signature of Funeral Director and/or Cemetery authority Federal ID number

SUMMARY OF AVAILABLE RESOURCES Contributions from Relatives and / or Friends: Insurance: Real Estate: Bank Balance: Cash on Hand: Fraternal Organization: Burial Plot: Available w/o Cost: Other (Specify): SECTION III B Reimbursement from Social Security Death Benefits ?
Y es No

ADDITIONAL LOCAL OFFICE COMMENTS Medicaid effective on: ____________________________________________________
Name of Local Office Contact Person Telephone number

(
COUNTY DIRECTOR'S CERTIFICATION

)

I hereby certify that the within claim covering burial expenses as indicated is in proper form; that the deceased recipient in whose behalf payment is to be made has been found to be eligible for such services under the provisions of IC 12-14-17, and that this claim in the amount of _____________ is being recommended for payment based upon information submitted to this Office by the Funeral Director and/or Cemetery Authority.
Signature of Director of Local Office, DFC, FSSA Signature of Authorized Designee

Date (month, day, year) Date (month, day, year)