Get Dshs 14 539

The Dshs 14 539 form is essential for individuals looking to designate funds for burial in relation to SSI-related healthcare. This guide provides step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to fill out the Dshs 14 539 form seamlessly.

1. Click ‘Get Form’ button to download the form and open it in your preferred editor.
2. Enter the case name and case number at the top of the form to identify your submission.
3. Provide the name of the applicant or recipient in the designated field, ensuring accuracy with spelling.
4. If applicable, fill in the name and relationship of the person making the statement in the specified areas.
5. Indicate whether you have funds set aside for burial by checking the appropriate box and ensure that the information provided is truthful.
6. Specify the amount of funds reserved for burial for yourself and your spouse in the designated fields.
7. Choose the correct option regarding whether the funds are held in a separate account and provide details about the account type, such as bank account or insurance policy.
8. Fill in the details of the bank, insurance company, or funeral provider holding the funds, including the name, address, and telephone number.
9. Acknowledge the reporting requirements to the Department of Social and Health Services by reading and understanding the listed obligations.
10. Complete the declaration section, including your signature and date, ensuring that the information provided is true to the best of your knowledge.
11. After ensuring all sections are accurately filled, you can save changes, download, print, or share the form as needed.

Begin filling out your Dshs 14 539 form online today for an efficient and organized submission.