(please complete all applicable fields - name of the deceased and date of death are required)
To: Director, Estate Recovery Program From: [Name]
Iowa Medicaid Enterprise [Funeral Home] P.O. Box 36445 [Street Address]
Des Moines IA 50315 [City, State, Zip]
Phone: 515-246-9841 / Toll-Free: 888-513-5186 [Phone]
Fax: 515-246-0155 [Fax]
[E-mail]
You are hereby notified that [name of deceased], [social security #], who had a non-guaranteed irrevocable burial trust fund, or life insurance or an annuity made payable or assigned to the funeral home, in the total amount of $, died [date of death], and a photocopy of the death certificate is attached to this notice. Final payment for funeral merchandise and funeral services has been made in the amount of $, and after an administrative fee of $50.00 for the funeral home, there remains $ in the irrevocable burial trust fund as of this date [date this form is sent].
The name and address of the contact person who is handling the affairs for the deceased is:
[name]
[street address]
[city, state, zip code]
[relationship to deceased]
[phone]
There is not a surviving spouse, as the deceased was divorced at the time of death, or never married. There is not a surviving spouse as the spouse predeceased the recipient. Date of death if spouse is deceased There is a surviving spouse whose name is ,
There is not a surviving spouse as the spouse predeceased the recipient.
Date of death if spouse is deceased
address/city/state/zip is ,
and Social Security Number is
The above named seller must receive a written response regarding any claim by the Estate Recovery Program within sixty days of the mailing of this notice to the Estate Recovery Program.
If the above-named seller (funeral home) does not receive a written response regarding a claim by the director within sixty days of the mailing of this notice, the seller may dispose of the remaining funds in accordance with the above-cited Code section. Disposing of these funds in accordance with this Code section will relieve the seller of liability pursuant to this section, but the funds may still be recoverable under Iowa Code Sections 249A.5(3) and 523A.303.
Revised 02/07