Fillable Funeral Final Disposition Benefit Application Fillable (Commonwealth of Massachusetts)

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Funeral Final Disposition Benefit Application Fillable (Commonwealth of Massachusetts)

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The Funeral Final Disposition Benefit Application Fillable (Commonwealth of Massachusetts) form is 3 pages long and contains:

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Page 1 of 3
Massachusetts Department of Transitional Assistance
Application for Funeral and Final Disposition Benefit
The Department may pay to a licensed funeral establishment up to $1,100 of the outstanding balance of
funeral and final disposition expenses of an eligible deceased person provided that the total cost and expense
of the funeral and final disposition does not exceed $3,500.
IMPORTANT! Please read!
This application must be completed by the deceased person’s surviving kin in the following order of
priority: spouse, adult child, parent, sibling, or other relative. If there are no surviving kin, this
application must be completed by the duly authorized legal representative of the deceased person. If
there is no surviving kin or duly authorized representative, this application may be completed by a
licensed funeral establishment.
A copy of the signed funeral services contract and/or itemized statement must be submitted with this
application if the applicant is someone other than a licensed funeral establishment.
Return this form by mail to: Department of Transitional Assistance
P.O. Box 4406
Taunton, MA 02780-9975
Or by fax to: (617) 887-8765
Section I:
Deceased Person’s Name ________________________________________________________________________
First Middle Last
Address _____________________________________________________________________ ___________________
Street City ZIP
SSN______________________ Date of Birth______________ Date of Death______________
Gender Male Female
Marital Status Single Married (Maiden Name) ______________________________________
Separated Divorced Widowed
Section II:
Check here if there is no surviving kin or duly authorized legal representative.
Name _______________________________________________________________________________________________
First Middle Last Relationship
Address _____________________________________________________________________________________________
Street City ZIP Telephone
F&FD-1 (Rev. 7/2019)
04-085-0719-05
Page 2 of 3
Was the deceased person receiving DTA benefits at the time of death? Check all that apply:
TAFDC Yes No
EAEDC Yes No
SSI/SSP* Yes No
SNAP Yes No
* Supplemental Security Income benefits and/or State Supplemental Payments.
Do the planned services include a burial? No Yes $ ________
Did the deceased person have any of the following assets at the time of death? (If Yes, provide value amount.)
Does the deceased have a pre-paid burial plot? No Yes $ ________
Does the deceased have a funeral trust account? No Yes $ ________
Has the deceased person been granted any other death benefit, e.g. Veteran’s or Social Security? (If Yes,
provide value amount.)
No Yes $ ________ Personal Needs Account(s) No Yes $ ________
Cash No Yes $ _______ Bank Account(s) No Yes $ ________
Other Assets No Yes $ _______ Other Asset Type: ________________________________
Does the deceased person have a life insurance policy? No Yes $ ________
If Yes, provide name of insurance company and policy number:
___________________________________________________________________________
Have/Will any of the deceased person’s assets been/be applied to the funeral bill? No Yes $ ________
Have or will funds be raised or collected (e.g. family and/or church donation, GoFundMe® or other
crowdfunding platform) to satisfy all or a portion of funeral and final disposition expenses?
No Yes $ ________
Do you (surviving kin) have any assets (bank accounts, cash, life insurance, etc.)? No Yes $ ________
If Yes, please provide verification ____________________________________________________________
Section III (TO BE COMPLETED BY LICENSED FUNERAL ESTABLISHMENT):
Name of Licensed Funeral Establishment:
___________________________________________________________
License No.: _________________________________________________
Address _____________________________________________________________________________
Street City ZIP Telephone
Is there a pre-need funeral services contract that controls the nature of the goods and services to be provided?
(If Yes, please provide value amount.)
No Yes $ _____________
Has/Will the licensed funeral establishment advance(d) monies as an accommodation to the surviving kin or
duly authorized representative making funeral arrangements? (If Yes, please provide value amount.)
No Yes $ _____________
Page 3 of 3
CERTIFICATION
To be signed by funeral establishment and surviving kin or duly authorized representative, if
applicable.
I have attached a true and accurate copy of supporting documentation, including but not limited to,
funeral services contract, death certificate, and itemized bills, statements, and invoices reflecting all
funeral and final disposition services provided or services that will be provided, receipts, pre-need
funeral services contracts, life insurance policy, and bank statements.
I certify, under penalty of perjury, that the information, including the information contained in any
supporting documentation, I have given in connection with this Application for Funeral and Final
Disposition Benefit is true and accurate to the best of my knowledge.
I understand that information on this application will be verified. Information available to the Department
will be used to process this application.
I understand the Department may recover from the estate of the deceased person any funeral and final
disposition benefit paid.
SURVIVING KIN OR DULY AUTHORIZED REPRESENTATIVE:
__________________________________________________
Printed Name of Applicant
__________________________________________________
Signature of Applicant Date
LICENSED FUNERAL ESTABLISHMENT:
__________________________________________________
Printed Name of Authorized Official Title
__________________________________________________
Signature of Authorized Official Date
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Funeral Final Disposition Benefit Application Fillable (Commonwealth of Massachusetts)

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Completed 18 July 2020

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