Burial Fund Referral Form

Pursuant to Iowa Code Chapters 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:
Funeral Home:
Street Address:
City: State: Zip:
Phone:
Email:

You are hereby notified of the death of:

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 .

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, insurance policy, or annuity as of this date .


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:

Contact person, if not surviving spouse:

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

The surviving spouse, if any, is:

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

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


The above named seller must receive a written response regarding any claim by the Estate Recovery Program within sixty days of sending 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.53(2) and 523A.303.