COVID-19 Funeral / Mortuary Assistance Application

Decedent Information

Full Name: *

Date of Death (MM/DD/YYYY): *

Place of Death (City/State): *

Residence at the time of Death (Physical Address): *

Funeral / Mortuary Service Information

Name of Mortuary / Funeral Service: *

Contact Person: *

Address *

Address

City

State/Province

Zip/Postal

Phone

Date of Service: *

Location of Service: *

Estimate cost of funeral service: *

Invoice Available:

Yes

No

If you answered yes above, please attach invoice.

Maximum file size: 52.43MB

Applicant Information

Fulle Name: *

Address *

Address

City

State/Province

Zip/Postal

Relationship to Decedent: *

Phone Number:

Documentation of Decedent's Wishes

Did the decedent have a will?:

Yes

No

If you answered yes above, please attach will.

Maximum file size: 52.43MB

Has a Personal Representitive Action been filed in any Court to which a Judge will decide who will have the authority to conduct funeral services.

Yes

No

If you answered yes above, please attach court documentation.

Maximum file size: 52.43MB

Funds Available for Funeral Services

Is there any personal burial assistance already available to the Decedent:

Yes

No

If you answered yes above, please attach information:

Maximum file size: 52.43MB

Cost of Funeral / Monetary Services: *

Minus Personal Resources *

TOTAL REQUESTED: *

Certification / Acknowledgment

Please certify your answers: *

1. I/we certify that approval of this application by the Blackfeet Tribe is for payment of services only. Proceeds will be paid to the Funeral/Mortuary Service as named in this application. This application does NOT approve who has the right to carry out the decedent's wishes. Legal documentation of the decedent's wishes may be evaluated prior to approval of this application if there are any disputes among family members of the decedent.

2. I/we certify that I/we please check with Blackfeet Incident Command on current restrictions governing funerals due to COVID-19. This may impact the cost of services.

3. I/we certify that the approval of the amount for funeral services is based upon the U.S. CARES Act Treasury Guidelines, which require that the death be caused by COVID-19 and that the decedent's funeral costs are not covered by any other source. This is a need-based application.

4. I/we certify that as the applicant, I hereby release to the Blackfeet Tribal Treasurer to receive information from the Funeral/Mortuary Service named in this application.

Applicant Signature *

Clear

Date *