(A) An applicant shall provide the
following information, if applicable, on the reimbursement application
form:
(1) Name of the
deceased;
(2) Decedent's
address at the time of death;
(3) Date of birth;
(4) Date of death;
(5) Place of death;
(6) Race/nationality;
(7) Supplier
identification number or federal identification number;
(8) Township or municipal corporation
name;
(9) Name of authorized representative or
designee submitting the application;
(10) Daytime telephone
number;
(11) Email
address;
(12) Disposition method;
(13) Date of burial or
cremation;
(14) County;
(15) Zip code;
(16) Cost of burial or
cremation;
(17) Date of burial
transit permit or disposition permit;
(18) Name of licensed funeral director
that performed disposition;
(19) Name of the cemetery or place of
interment;
(20) Name of funeral home;
(21) Total reimbursement
claim amount.
(B) An original or legible copy of the
following documents, if applicable, shall be attached and submitted with the
reimbursement application form:
(1) An affidavit or
statement of indigency status determined by the local government
entity;
(2) A statement of goods
and services from the licensed funeral director;
(3) Receipts of charges and payments for
goods and services;
(4) The cremation authorization form;
(5) The burial transit or disposition
permit;
(6) If applicable, the contract or formal
agreement between the local government entity and the funeral home to perform
final disposition of indigent persons for the local government entity.
(C) When there is a dispute or question
relating to the application, the board shall contact the local government
entity, its authorized representative, or designee.
(D) The local government entity, its
authorized representative, or designee shall submit the reimbursement
application form to the board by electronic mail or mail.
