Fillable Form M-860w (E) 05/07/2020 (page 1 of 8) (City of New York)

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Form M-860w (E) 05/07/2020 (page 1 of 8) (City of New York)

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The Form M-860w (E) 05/07/2020 (page 1 of 8) (City of New York) form is 8 pages long and contains:

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  • 14 check-boxes
  • 175 other fields

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File type: PDF

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Office of Burial Service
s
33-28 Northern Boulevard, 3rd Floor
Long Island City, New York 11101
Telephone Number: 929-252-7731
Form M-860w (E) 05/07/2020 (page 1 of 8) LLF
Today's Date:
Burial Claim Number:
Application for Burial Allowance
A. Information about the decedent (person who died):
Name of decedent:
(Last Name, First Name)
Last known address of decedent:
How long did the decedent live there?
Was the decedent in a NYC homeless shelter? No Yes
Date of Birth: Date of Death:
Social Security Number (if known):
Cause of Death (if known):
Place of Death (Hospital, Home, other if known):
Has the decedent been buried? No Yes
Has the decedent been cremated? No Yes
Was the decedent married? No Yes
If Yes, provide name, address and telephone number of spouse:
Was the decedent under the age of twenty-one (21)? No Yes
If Yes, provide name, address and telephone number of parent(s) or legal guardian:
(Turn page)
Form
M
-860w (E) 05/07/2020 (page 2 of 8
)
LLF
Human Resources Administratio
n
Emergency Intervention Services
Application for Burial Allowance (continued)
B. Decedent Veteran's Status:
Was the decedent a veteran? No Yes
Branch of Service, if known (Army, Navy, etc.):
Was the decedent a spouse of a Veteran? No Yes
Was the decedent a minor child of a Veteran? No Yes
Have Veteran burial or death benefits been paid by any government agency? No Yes
If Yes, how much (provide details):
Did the decedent receive any Veteran's benefits? No Yes
If Yes, how much (provide details):
C. Decedent Financial Histor
y
Describe how the decedent was financially supported:
Was the decedent employed at the time of death? No Yes (If Yes, please provide
details)
Name of Employer:
Address:
Telephone:
Type of employment:
Were employer death benefits paid? No Yes (If Yes, please provide details)
(Turn page)
Form
M
-860w (E) 05/07/2020 (page 3 of 8
)
LLF
Human Resources Administratio
n
Emergency Intervention Services
Application for Burial Allowance (continued)
C. Decedent Financial History (continued)
Did the decedent receive any assistance from HRA? No Yes
If Yes, Case Number (if known)
Check all that apply: Cash Assistance Medicaid/MA
Supplemental Nutrition Assistance Program SNAP (food stamps)
Other
Did the decedent receive Social Security Administration Benefits? No Yes
If Yes, check all that apply:
Supplemental Security Income (SSI)
Amount: $
Social Security Disability (SSD)
Amount: $
Social Security Old Age, Survivors, and Disability
Insurance (OASDI)
Amount: $
D. Decedent Estate Informatio
n
Did the decedent have a will? No Yes
Does the decedent have an estate? No Yes
If Yes, name and contact information of the individual responsible for the will or estate
Is there any court case concerning the decedent? No Yes
If Yes, please provide details: County, Court, File Number, Name and Contact information of
Estate Representative or Attorney involved
(Turn page)
Form
M
-860w (E) 05/07/2020 (page 4 of 8
)
LLF
Human Resources Administratio
n
Emergency Intervention Services
Application for Burial Allowance (continued)
E. Decedent's Assets or Personal Propert
y
If the decedent had any assets or personal property at the time of death, please check all
that apply and provide the value or amount if known:
Cash
No Yes $
Vehicle(s)
No Yes $
Real
Property
No Yes $
Insurance/
Policies
No Yes $
Pension
No Yes $
Burial Trust/
Prepaid Burial Fund
No Yes $
Bank
Accounts
No Yes $
Stocks, Investment
Accounts
No Yes $
Union
Benefits
No Yes $
Other, pending
lawsuit or settlement
No Yes $
Does the Public Administrator have any of the decedent’s property or assets? No Yes
If Yes, please provide the details, value or amount if known and contact information for the
Public Administrator:
You may be required to provide additional information about the deceden
t
’s assets. Please
use the space below for additional details about the location of the assets or personal
property:
(Turn page)
Form
M
-860w (E) 05/07/2020 (page 5 of 8
)
LLF
Human Resources Administratio
n
Emergency Intervention Services
Application for Burial Allowance (continued)
F. Applicant Informatio
n
Relative Friend Organizational Friend Authorized Representative
Name:
(Last Name, First Name)
What is your relationship to the decedent?
Address:
Telephone: Email:
G. Legally Responsible Relative Informatio
IMPORTANT: A legally responsible relative (LRR) is a person who is legally married to the
decedent or the parent or legal guardian of a decedent who is under the age of 21 twenty-
one and lived in the same household with the decedent at the time of death.
Are you a legally responsible relative? No Yes
If No, Skip the questions below and go to section H.
If Yes, please complete the questions below and on the following page.
I am a Spouse of the decedent (OR)
I am a parent or legal guardian of decedent under age twenty-one (21).
Are you financially able to pay for the funeral costs? No Yes
If Yes, Skip the questions below and go to section H.
If No, please complete the following:
Name:
Date of Birth: Social Security Number:
Address:
Telephone: Email:
(Turn page)
Form
M
-860w (E) 05/07/2020 (page 6 of 8
)
LLF
Human Resources Administratio
n
Emergency Intervention Services
Application for Burial Allowance (continued)
G. Legally Responsible Relative Information (continued)
Do you receive any assistance from HRA? No Yes
If Yes, Case Number (if known)
Check all that apply: Cash Assistance Medicaid/MA
Supplemental Nutrition Assistance Program SNAP (food stamps)
Other
Are you receiving Social Security Administration Benefits? No Yes
If Yes, check all that apply:
Supplemental Security Income (SSI)
Amount: $
Social Security Disability (SSD)
Amount: $
Social Security Old Age, Survivors, and Disability
Insurance (OASDI)
Amount: $
H. Information about funeral costs (burial, cremation or other funeral costs):
Have the funeral costs been paid? No Yes
If No, have funeral arrangements been made for the decedent? No Yes
For paid funeral costs, did the applicant pay No Yes
If No, and someone else paid the funeral costs, provide the name, address and telephone
of the person(s) that paid the bill:
Name:
(Last Name, First Name)
Address:
Telephone Number:
(Turn page)
Form
M
-860w (E) 05/07/2020 (page 7 of 8
)
LLF
Human Resources Administratio
n
Emergency Intervention Services
Application for Burial Allowance (continued)
H. Information about funeral costs (burial, cremation or other funeral costs)
(
continued
)
:
Name of Funeral Home:
Address and Telephone:
Total Cost of Funeral Expenses: $
(Total amount on the bill or contract)
Specify the cost of the following:
Cremation: $ Burial Plot: $ Grave Opening: $
The person signing this form authorizes the Commissioner of the New York City Department
of Social Services or his/her authorized representative to make all inquiries necessary in
relation to this application and gives them full permission to have any or all of the information
in this application verified.
Print Name:
Signature of Applicant: Date:
(Turn page)
click to sign
signature
click to edit
FOR AUTHORIZED REPRESENTATIVES ONLY
If you are not the applicant and you are authorized to complete this application for the
applicant you must sign this form in front of a Notary Public or Commissioner of Deeds.
Form
M
-860w (E) 05/07/2020 (page 8 of 8
)
LLF
Human Resources Administratio
n
Emergency Intervention Services
Application for Burial Allowance (continued)
State of
County of
Sworn to before me this day of , 20
Notary Public or Commissioner of Deeds
Do you have a medical or mental health condition or disability? Does this condition
make it hard for you to understand this notice or to do what this notice is asking? Does
this condition make it hard for you to get other services at HRA? We can help you. Call
us at 212-331-4640. You can also ask for help when you visit an HRA office. You have a
right to ask for this kind of help under the law.
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Form M-860w (E) 05072020 (page 1 of 8) (City of New York)

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Completed 10 October 2020

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