Application For County Burial Allowance
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PPLICATION FOR
OUNTY
URIAL
LLOWANCE
Name of Deceased:
Address of Deceased:
Name of Veteran (if other than
above):
Address of Veteran (if deceased, so indicate):
Veteran’s Branch of Service:
Date of Enlistment:
Date of Discharge:
Honorably Discharged:
Yes
No
Date of Death of Deceased:
Residence at Time of Death (Place, City, State, County):
Residence the Year Prior to Death (Place, City, State, County):
Surviving Dependents of Deceased:
Age:
Relationship:
Name of Mortician/Funeral Home:
Phone Number:
Total Expenses Incurred for Funeral and Burial:
Name of Person Incurring Funeral Expenses:
Phone Number:
Address:
Name of Applicant:
Phone Number:
Address:
Relationship of Applicant to Deceased:
Property of Deceased
Did deceased have Life Insurance?
Yes
No
If yes, name of beneficiary:
Amount
$
If yes, payable to estate of deceased?
Yes
No
Amount
$
Cash, Checking Account, Savings Account, Stocks, Bonds, or other Securities (individually or jointly held):
Yes (if so list each below)
No
Amount
$
Amount
$
Amount
$
Amount
$
Amount
$
Excluding Home, Car and Personal Property, Assets are less than $40,000
Yes
No
Attestation of Applicant
____________________________________ states, under penalty of perjury, that he/she completed the foregoing Application for County
Burial Allowance and that facts therein contained are true according to his/her best knowledge and belief.
Signature of Applicant_______________________________________________________________________
Date:
____________
OCDVA – 001 (9/21/2012)
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