Burial Fund Referral Form

Pursuant to Iowa Code Chapters 249A.5(2) and 523A.303

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 #], , date of birth, 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]. 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 [date this form is sent].

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 code]

[relationship to deceased]

[phone]

The surviving spouse, if any, is:

[name]

[street address]

[city, state, zip code]

[social security number]

[date of birth]

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

The deceased was never married.

The deceased was married, and further:

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.5(2) and 523A.303.

Revised 6/10

Use the button below to submit the form. The following page will allow you to print a copy for your records.