Health and Wellness Service Team Financial Assistance Services Burial Specialist Phone 651-706-2946 Fax: 651-266-3932 Application for Ramsey County Assisted Burial Funds Date ______Applicant Your Name Relationship to Decedent Your Address , State Zip code Phone Number with Area Code Cell Phone Number Decedent Information Decedent Name Gender Race Hispanic Yes No Social Security Number Age Birthdate date Veteran Status Decedent’s Marital Status at Death Last address City, State Zip code Decedent’s Assets and Resources Checking: Bank Route # Acct # Balance $ Savings: Bank Route # Acct # Balance $ Life Insurance Company Policy # Amount $ Veteran Death Benefit YES NO Amount $ Social Security Death Benefit YES NO Amount $ Other Death Benefit Amount $ Prepaid Burial with Amount $ Payee Name Cash $ Other Assets (car make/year, etc) Decedent’s Burial Assets (if pre-arranged, complete this section) Name of Lot # or Name Liner/Vault Casket Interment Costs Is there an estate for probate? YES NO If yes, in what county? Responsible Relative’s Income and Resources (if applicable) Spouse’s Name Monthly Income $ or Annual Income $ Bank Name Route # Acct # Balance $ Additional Accounts Information If decedent is under age 18, please complete the following: Mother’s Mo. Income $ Bank Route # Acct # Balance $ Additional Accounts Information Father’s Mo. Income $ Bank Route # Acct # Balance $ Additional Accounts Information

Applicant’s Signature Date

RCHW 3131 FAS Revised: 10/2019 1 Application for Ramsey County Assisted Burial Funds

(Page Two to be Completed by Home) ’s Name Funeral Home Name Phone Number with Area Code Funeral Home Address City, State Zip code Services Requested Adult (13 Years or Older) Youth (Age 1-13) (Stillborn to one year) Type of Service: Funeral Direct Cremation with Funeral Service Memorial Service Cemetery Name Phone # Cemetery Address City, State Zip code Notes:

Please contact Ramsey County Financial Assistance Services with questions about this application. The burial specialist’s phone number is 651-706-2946. Fax the completed application to: “Attention burial specialist” at 651-266-3932.

Ramsey County Use Only Do not Write Below This Line

Funeral Director $ Casket (Oversize) $ Vault (Oversize) $ Cremation $ Cemetery $ Total Cost $ Resources Ramsey County Payment $ Approved Referred to County Attorney Denied Reason for Denial

RCHW 3131 FAS Revised: 10/2019 2