Document Upload Form

Application for General Assistance Burial - Cremation Funding & Information Required for General Assistance Burial - Cremation Funding
INFORMATION OF PERSON FILLING APPLICATION OUT
Name of person filling application out on behalf of the deceased person.*

First NameLast Name
What is your relationship to the deceased person. *
Email of person filling application out on behalf of the deceased person.*
example@example.com
Phone number of person filling application out on behalf of the deceased person.*
Please enter a valid phone number.
APPLICATION
Name of the deceased person.*

First NameLast Name
Last 4 of Social Security Number of deceased person.*
Date of Birth of deceased person.*

MonthDayYear
Date
Date of death of deceased person.*

MonthDayYear
Date
Address of deceased person.*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship Status of deceased person.*

MarriedWidowedDivorcedSeparatedSingleOther
Was deceased person a student?*

YesNo
Did deceased person have life insurance?*

YesNo
Did deceased person have burial or other insurance?*

YesNo
Veteran Status (Was deceased a veteran?)*

YesNo
Did deceased person have health/hospital insurance?*

YesNo
What funeral home are you working with? *

Did deceased person have any of the following?*

	Yes	No	Amount
Checking Account
Savings Account
Venmo
PayPal
Chime
Apple Pay
Cash App
Direct Express
Other

Did deceased person have any of the following?*

	Yes	No	Amount	How Often is Income Received
Social Security (SSI, SSDI, Retirement Benefits, etc..
Veterans Benefits
Soldiers Relief
Earnings (Wages)
Unemployment Benefits
Workers Comp
FIP
SNAP Food Benefits
Child Support
Foster Care Income
Other

Employment history of deceased person for the last year (start with most recent position).

	Employer	City of Employer	Kind of Work	Start Date	End Date	Hourly Wage	Reason for Discontinuing
Most Recent Job
Second Job
Third Job
Forth Job

Was deceased person an American citizen?*

YesNo
Your signature is also an authorization for this office to obtain verification of facts given on this form.

You may be required to sign an additional authorization for release of information form(s) to allow the Warren County General Assistance office to gather additional verification of information provided.

I hereby certify that the statements made herein are true and correct to the best of my knowledge and belief. I further understand that I may be legally prosecuted for intentionally making false statements in order to receive assistance.

Public Record Disclosure Notice

Please be advised that applications for Health Navigation and/or General Assistance are subject to review and approval by the Warren County Board of Supervisors/Warren County Board of Health . As part of this process, your first and last initials may appear on public records, including meeting agendas and minutes, in accordance with Iowa Open Records laws. These records may include references to assistance claims requiring board approval.

By submitting this application, you acknowledge and understand that limited personal identifiers (i.e., initials) may be included in publicly available documents related to your request for assistance.
Signature of person filling application out on behalf of the deceased person.*

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If you are dissatisfied with the action of this office, you may appeal to the Warren County Board of Supervisors, Court House, Indianola, Iowa.

PROHIBITION AGAINST DISCRIMINATION
We will consider this application without regard to race, color, sex, age, handicap, religion, national origin, or political belief.
If you feel you have been the object of such discrimination, you may file a complaint in letter form with the Warren County Board of Supervisors, Administration Building, Indianola, Iowa.

CONFIDENTIALITY
All applicants and/or recipients have the right to confidential treatment of information concerning their situation; however, it should be understood that such information may be shared with other employees of Warren County, including the Warren County Board of Supervisors. A certain amount of information may need to be released to direct providers of service, such as pharmacies, hospitals, doctors, landlords, utility providers, etc., in order to authorize release of goods to the client. In certain instances when the General Relief employee is working cooperatively with other agencies, i.e., Veterans Affairs, Community Action Center, and/or County department, certain information may be released in order to complete transactions.
AUTHORIZATION FOR RELEASE OF INFORMATION
I voluntarily allow information to be exchanged between Warren County General Relief and the following agencies/organizations for the coordination of services:

Utility ProvidersFuneral HomeChild Support Recovery UnitIMPACT Community Action PartnershipIowa Workforce DevelopmentLandlord / Property ManagerPharmacyPrevious EmployersWarren County Veteran's AffairsIowa Vocational Rehabilitation ServicesWeLift Job Search CenterSalvation Army of Central IowaAging Resources of Central IowaMinisterial Fund AllocatorsIowa Legal AidIowa Community HubRolling Hills Central Iowa Shelter & ServicesWarren County Housing AuthorityHeal HouseIowa Finance AuthorityDepartment of Health and Human ServicesChildren and Families of IowaIowa MedicaidSNAPMedicareSHIP & SMPInsurance ConsultantSocial Security AdministrationWarren County Health ServicesWarren County Attorney's OfficeMental Health ProviderSubstance Use ReferralEducation InstitutionOther
I Voluntarily allow Warren County General Assistance to communicate with me:

Electronically by the email provided.To call the phone number provided.To leave a voicemail at the phone number provided.Other
Signature of person filling release of information out on behalf of the deceased person.*

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Information Required for General Assistance Funding
Please upload (the deceased persons) proof of income for the most recent 30 days here.

Cancelof
Please upload (the deceased persons) all money transactions form the most recent 30 days here.

Cancelof
Should be Empty:

Application for General Assistance Burial - Cremation Funding & Information Required for General Assistance Burial - Cremation Funding

INFORMATION OF PERSON FILLING APPLICATION OUT

APPLICATION

AUTHORIZATION FOR RELEASE OF INFORMATION