Fillable STATEMENT OF APPLICANT/RECIPIENT DESIGNATING BURIAL FUNDS (State of Nevada, Department of Information Technology)

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STATEMENT OF APPLICANT/RECIPIENT DESIGNATING BURIAL FUNDS (State of Nevada, Department of Information Technology)

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BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

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STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
STEVE SISOLAK
Governor
2006 - EG (232.0.0)
Page 1 of 1
/ /
RICHARD WHITLEY, MS
Director
STEVE H. FISHER
Administrator
TANF MEDICAID SNAP
Date:
Case Name:
Case ID:
STATEMENT OF APPLICANT/RECIPIENT DESIGNATING BURIAL FUNDS
1. In what form are the funds held? (burial contract, bank account, life insurance policy, etc.)
2. For whose burial are the funds set aside?
3. Who is the owner of the funds?
4. What is the current value of this resource?
5. How long have you held these funds?
6. Have you needed to use these funds in the past for another reason? YES NO
If YES, when did this occur and why?
COMMENTS:
Client Signature Print Name Date Telephone Number
Case Manager Signature Print Name Date Telephone Number
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STATEMENT OF APPLICANTRECIPIENT DESIGNATING BURIAL FUNDS (State of Nevada, Department of Information Technology)

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Completed 5 August 2021

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