Fillable APPLICATION FOR BURIAL ASSISTANCE (Native Village of Eyak)

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APPLICATION FOR BURIAL ASSISTANCE (Native Village of Eyak)

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BIA ALASKA REGION HUMAN SERVICES
APPLICATION FOR BURIAL ASSISTANCE
Name of Deceased:
Deceased’s Date of Birth: Date of Death:
Tribe Enrolled To: Tribal Enrollment #:
Deceased’s Last Address:
P.O. Box or Street Address City State Zip
***The deceased must have resided in the service area.***
Name of Relative Applicant: _________________________________________________________
Relationship to Deceased: ____________________________________________________________
Mailing Address: ___________________________________________________________________
P.O. Box or Street Address City State Zip
Home Phone#: Message Phone#: Work Phone#:
What are the plans you have arranged for the burial?
Name of Mortuary:
Address:
City: State: Zip Code:
Contact Person: Phone: Fax:
Will the casket be built? Yes No If yes, by whom? Please write information below.
Name: Address:
BIA ALASKA REGION HUMAN SERVICES
City: State: Zip: Phone:
Building Material Cost: $
Vendor Name:
Address:
City: State: Zip Code:
Contact Person: Phone: Fax:
Did the deceased have an Individual Indian Money (IIM) account? *Yes No
*If YES, please contact Gloria Gorman at the BIA (907) 271-4111 / gloriak.gorman@bia.gov
RECORD OF INCOME AND RESOURCES
Did the DECEASED have income from any source? Yes No
If yes, please list source of income and amounts below.
***Applicant MUST provide proof of ALL income & resources***
SOURCE OF INCOME
AMOUNT
Salary #1: Deceased's Income/Salary
$
Salary #2: Surviving Spouse's Income/Salary
$
Life Insurance
$
*State of Alaska ATAP/Tribal TANF
$
*Adult Public Assistance (APA)
$
Social Security (SSA) or SS Retirement
$
Supplemental Security Income (SSI)
$
Disability Insurance
$
Alaska Permanent Fund Dividend (PFD)
$
Cashouts of Retirement or Pension Plans
$
State Longevity
$
Veteran's Benefit
$
Unemployment Insurance Benefits (UIB)
$
Worker's Compensation
$
Medicare/Medicaid
$
Native Corporation Dividends
$
Native Corporation Dividends
$
Checking Account
$
Savings Account
$
Donations – Community and/or Churches
$
Donations
$
TOTAL MONTHLY INCOME
$
READ BEFORE SIGNING
BIA ALASKA REGION HUMAN SERVICES
I apply for financial assistance for burial assistance services for the deceased who is in need. I, have received
a copy of and have had explained to us, and understand the provisions of Federal Law governing fraud. I
agree to supply information regarding resources and income and to notify the agency of any changes in my
situation. Social Services is authorized to obtain information necessary to establish eligibility for assistance.
I have read, or had explained to me, the provision of my protection under the Paperwork Reduction Act and
the Privacy Act.
Relative Applicant Signature
Printed Name
Date
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APPLICATION FOR BURIAL ASSISTANCE (Native Village of Eyak)

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Completed 27 January 2021

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