Bank and Credit Union Referral Form

Pursuant to Iowa Code Section 249A.53(2) and 523A.303

To: Estate Recovery Program
Iowa Medicaid
P.O. Box 13110
Des Moines, IA 50310
Phone: 515-246-9841 / Toll-Free: 877-463-7887
Fax: 515-246-0155

From:
Bank:
Street Address:
City: State: Zip:
Phone:
Email:

You are hereby notified of the death of:

Name:
Date of Death:
Date of Birth:
Social Security Number:

The surviving spouse, if any, is:

Name:
Street Address:
City: State: Zip:
Social Security Number:
Date of Birth:

The name and address of the contact person who is handling the affairs for the deceased is the surviving spouse listed below, or if not, as follows:

Name:
Street Address:
City: State: Zip:
Relation to Deceased:
Phone:

The deceased had an account with our bank with $
remaining in the account on the date of death.
The account number is:

Our intentions with regard to these funds are as follows (Check one):


Further information regarding the marital status of the deceased is as follows:


The resident has used or his or her representative will likely use the services of the following:

Funeral Home:
City:
Attorney:
City:
Executor:
Bank:
Account #:
City:

Other information that may be helpful:

0/500

For burial trust funds:

You are hereby notified that the above named deceased person, who had a social security number and death date as identified above, had a non-guaranteed irrevocable burial trust fund. Final payment for funeral merchandise and funeral services has been made, and $ remains in the irrevocable burial trust fund as of the date of this notice The name and address of the contact person who is handling the affairs for the deceased is identified above.

The above named seller of the burial trust fund (the bank or credit union) 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 (bank or credit union) 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.53(2) and 523A.303.