Burial Assistance Application Checklist
Burial Assistance Application Checklist Burial Assistance Program Email: Burial@yuroktribe.nsn.us
The Yurok Tribal Burial Assistance Program offers compassionate financial support to assist with burial expenses for deceased Yurok Tribal members whose estates lack sufficient resources. Assistance is available regardless of service area and is intended to ease the financial burden during times of loss. The Yurok Tribal Burial Assistance Program may be able to assist with final expenses such as: Chapel/Mortuary Services, Caskets/Urns, Headstones, Burial Plots, Flowers, Death Certificates, and Newspaper Announcement.
Application Checklist
Verification of Death (e.g. Death Certificate, Newspaper Obituary, Verification from Mortuary)
Invoice from Funeral Home or other Service Providers
W9 for Funeral Home or other Service Provider (Outside of the Service Area)
Copy of Life Insurance Information/Policy, if applicable
Verification of Death (e.g. Death Certificate, Newspaper Obituary, Verification from Mortuary)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Invoice from Funeral Home or other Service Providers
Browse Files
Drag and drop files here
Choose a file
Cancel
of
W9 for Funeral Home or other Service Provider (Outside of the Service Area)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Copy of Life Insurance Information/Policy, if applicable
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Burial Assistance Application
Applicant Information:
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Relationship to the Deceased
*
Phone Number
*
Please enter a valid phone number.
DOB
*
-
Month
-
Day
Year
Date
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (If Different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Back
Next
Deceased Information:
Name
*
First Name
Last Name
Tribal ID
*
DOB
*
-
Month
-
Day
Year
Date
Date of Death
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Service Area
*
Del Norte
Humboldt
Trinity
Out of Service Area
District
*
North
South
East
Requa
Weitchpec
Pecwan
Orick
Did the Deceased have Life Insurance?
*
Yes
No
If yes, Amount:
Please list any Income and Resources available to the Deceased (include SSI, veterans' death benefits, social security, and Individual Indian Money (IIM) accounts, etc:
*
Name
Amount
Social Security/SSI
Veteran Benefits
Pension/Retirement
IIM Account
Other Resources
Total
*
Back
Next
Anticipated total of Burial/ Funeral expenses
*
Amount requested from Yurok Tribe Burial Assistance Program
*
Burial Assistance Acknowledgements & Authorization to Release Information:
*
I understand that I will be required to provide verification of Life Insurance for the Deceased, Invoices for services provided, W-9 for Vendors, etc.
*
I understand my application will remain active for ten (10) days in order to give me the opportunity to collect the documentation needed. After ten (10) days, the application will be inactive and I will need to re-apply again if assistance is still needed.
*
I hereby release the Yurok Tribe and its agents and employees from any/ all liabilities, responsibilities, damages and claims which might result from release of information authorized above.
*
I authorize Client Services Department, a department of the Yurok Tribe, and the organizations and/or individuals indicated below by to release and receive information concerning burial/funeral arrangements for the deceased listed above.
By signing below, I am certifying that all information provided, oral and written are true. I acknowledge that such information is subject to verification and that falsification of this information shall be grounds for denial and/or reimbursement of funds received from this program. This release will be in effect for one year from the date it is signed unless terminated earlier at the request of the client.
Applicant Signature:
*
Date
-
Month
-
Day
Year
Date
Co-Applicant Signature (other household adults)
Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
Submit
Should be Empty: