Fillable Burial Assistance Grant Application (The Chickasaw Nation)

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Burial Assistance Grant Application (The Chickasaw Nation)

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Form no. 04912 CS-SS Rev. 6/2019
Burial Assistance Grant Application
====================================================================================
Area offices: Addresses and contact information:
Ada 231 Seabrook Road / Post Office Box 1548 / Ada, Oklahoma 74820
(580) 436-7256 / FAX (580) 436-2109
Ardmore 949 Locust / Ardmore, Oklahoma 73401
(580) 226-4821 / FAX (580) 226-6732
Duncan 1819 West Plato Road / Duncan, Oklahoma 73533
(580) 470-2131 / FAX (580) 470-2129
Pauls Valley 20118 South Indian Meridian Road / Pauls Valley, Oklahoma 73075
(405) 207-9883 / FAX (405) 207-9876
Purcell 1430 Hardcastle Boulevard / Purcell, Oklahoma 73080
(405) 527-4973 / FAX (405) 527-8058
Sulphur 4970 West Highway 7 / Post Office Box 538 / Sulphur, Oklahoma 73086
(580) 622-2888 / FAX (580) 622-7102
Tishomingo 815 East 6
th
Street / Post Office Box 192 / Tishomingo, Oklahoma 73460
(580) 371-9512 / FAX (580) 371-3845
Oklahoma City 4001 North Lincoln / Oklahoma City, Oklahoma 73105-5206
(405) 767-8971 / Toll Free 1-866-466-1481 / FAX (405) 767-8968
====================================================================================
The burial assistance grant will pay up to $2,500 toward the final balance of the burial expense. The payment
will be made directly to the funeral home. Reimbursements will not be issued.
Documentation needed:
A copy of tribal citizenship in a federally recognized tribe.
A copy of certificate of death.
Current verification of deceased address (if within Chickasaw Nation service area).
A copy of the finalized statement from the funeral home.
Income verification of deceased’s household (if within Chickasaw Nation service area).
Bill Anoatubby
Governor
Department of Community Services / Social Services Division
Form no. 04912 CS-SS Rev. 6/2019
Burial Assistance Grant Application
If the deceased had a pre-paid burial plan which has paid or will pay the entire cost of the funeral and burial,
the deceased is not eligible for this burial assistance grant.
PLEASE SUBMIT ALL INFORMATION WITHIN SIX MONTHS FOLLOWING THE DEATH.
Full name of deceased (please include name in which CDIB was issued, if applicable)
Date of death
Address of deceased (address, state and ZIP):
Phone number of funeral home:
Address of funeral home (address, state and ZIP):
Phone number of person making application:
Address of person making application (address, state and ZIP):
I fully understand this application and I certify that all the information contained here is true and
correct. I hereby give permission for the funeral home listed above to release information to the
Chickasaw Nation assistance program which would assist in determining my eligibility.
Relation to deceased:
Date:
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
For Office Use Only
Prior to approval, the following documents must be attached:
Copy of CDIB, citizenship card or tribal letter Copy of certificate of death certificate
Copy of Social Security card Copy of final itemized statement
Verification of deceased’s address Verification of income, if applicable
Date received:
Date approved:
Approved amount:
Approved by:
BIA:
Tribal:
Department of Community Services / Social Services Division
Bill Anoatubby
Governor
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Burial Assistance Grant Application (The Chickasaw Nation)

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Completed 31 January 2021

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