Bank and Credit Union Referral Form

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

To:       Estate Recovery Program                                               From:   [Name]

Iowa Medicaid                                 [Bank]
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]


You are hereby notified of the death of:
Date of Death:
Date of Birth: 
Social Security Number:
The surviving spouse, if any, is:
[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 spouse as listed above, or if not, is as follows:


            [street address]

            [city, state, zip code]

            [relationship to deceased]



The deceased had an account with our bank with  $ remaining in the account on the date of death.  The account # is: . Our intentions with regard to these funds are as follows (Check one):

Remit to contact person named above

Remit to funeral home

Remit to the attorney if an estate will be opened

Hold the funds until further notice from the Estate Recovery Program

Other (please describe)

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 recipient has used, or his or her personal representative will likely use, the services of the following:

Funeral Home City

Attorney City Executor

Bank Account # City

Other information that may be helpful:

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 [date this form is sent]. 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.
Use the button below to submit the form. The following page will allow you to print a copy for your records.