Rule 4717-17-03 | Reimbursement Application Form.
(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.
Last updated October 2, 2023 at 12:17 PM
Supplemental Information