To: Estate Recovery Program From: [Name]
Iowa Medicaid 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]
Name:
Date of Death:
Date of Birth:
Social Security Number:
The surviving spouse, if any, is:
[name]
[street address]
[city, state, zip code]
[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 above, or if not, as follows:
[relationship to deceased]
[phone]
Further information regarding the marital status of the deceased is as follows: The deceased was never married. The deceased was married, and further: The deceased was divorced at the time of death. The deceased was preceded in death by a spouse: Name: Social security number: Date of birth: Date of death: The deceased has used or will likely use the services of the following: Funeral Home City Attorney City Executor Bank Account # City Other information that may be helpful: Use the button below to submit the form. The following page will allow you to print a copy for your records.
The deceased was never married.
The deceased was married, and further:
The deceased has used or will likely use the services of the following:
Funeral Home City
Attorney City Executor
Bank Account # City
Other information that may be helpful: