Get Dfa 67 A Form

The Dfa 67 A Form is an essential document used for burial billing in West Virginia. This guide will provide you with clear, step-by-step instructions on how to complete this form online effectively, ensuring that you provide all necessary information accurately.

Follow the steps to fill out the Dfa 67 A Form online:

1. Click the ‘Get Form’ button to obtain the Dfa 67 A Form and open it for editing.
2. Enter the information regarding the deceased in Part I. Include details such as the county office of the West Virginia Department of Health and Human Resources, the deceased's name and address, date of death, date of interment, and date of cremation.
3. Indicate whether the deceased is potentially eligible for Social Security or Veteran’s Administration death benefits by selecting 'Yes' or 'No'. If 'Yes', indicate if you have applied for these benefits.
4. In Part II, provide the name and address of the person arranging the burial service.
5. In Part III, list known living relatives of the deceased, and provide their relationship, county, and state of residence.
6. Part IV is the designated relative's statement. If applicable, the person arranging the burial service must certify their financial situation by signing and dating this section.
7. In Part V, the funeral home will complete this section, entering details about the maximum cost and payment eligibility, along with the certification fields.
8. Finally, review all entered information for accuracy. Once confirmed, you can save any changes made, download the document, print, or share it as needed.

Complete your Dfa 67 A Form online today to ensure a smooth processing experience.