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Get HI DHS 1163 2011-2024

Applicant s Signature Date. FOR OFFICIAL USE ONLY VI. Disposition Application is Approved Denied Discontinued Explanation/reason for disposition Printed Name of Eligibility Worker DHS 1163 Rev. 12/11 Authorized Eligibility Worker s Signature. STATE OF HAWAII Department of Human Services Med-QUEST Division DEATH PAYMENTS PROGRAM APPLICATION Please attach a copy of the death certification if one is available I. Decedent s information Decedent s Name Sex Social Security No* Date of Birth Veteran VA File Number II. Date of Death Applicant s information Applicant s Name Relationship to Decedent Applicant s Mailing Address III. Are any full funeral benefits available to the decedent such as pre-paid funeral or burial plans insurance plans associations and clubs Full funeral benefits mean funeral and/or burial services that provide a complete and dignified disposal of the decedent. Yes No IV. Has anyone received or expect to receive the lump-sum death payment benefit from Social Security for the decedent V. I understand that the Department of Human Services may recover for payments made by the Death Payments Program from the Veteran s Administration VA or the estate of the decedent. I certify the information I have provided on this application is true to the best of my knowledge. If I intentionally make false statements on this application I may be prosecuted under Hawaii Revised Statutes 346-43. 5 or other criminal laws. I further certify that the Death Payments Program payment shall be made to me and sent to my address as listed under item II above. STATE OF HAWAII Department of Human Services Med-QUEST Division DEATH PAYMENTS PROGRAM APPLICATION Please attach a copy of the death certification if one is available I. Decedent s information Decedent s Name Sex Social Security No* Date of Birth Veteran VA File Number II. Decedent s information Decedent s Name Sex Social Security No* Date of Birth Veteran VA File Number II. Date of Death Applicant s information Applicant s Name Relationship to Decedent Applicant s Mailing Address III. Date of Death Applicant s information Applicant s Name Relationship to Decedent Applicant s Mailing Address III. Are any full funeral benefits available to the decedent such as pre-paid funeral or burial plans insurance plans associations and clubs Full funeral benefits mean funeral and/or burial services that provide a complete and dignified disposal of the decedent. Are any full funeral benefits available to the decedent such as pre-paid funeral or burial plans insurance plans associations and clubs Full funeral benefits mean funeral and/or burial services that provide a complete and dignified disposal of the decedent. Yes No IV. Has anyone received or expect to receive the lump-sum death payment benefit from Social Security for the decedent V. Yes No IV. Has anyone received or expect to receive the lump-sum death payment benefit from Social Security for the decedent V. I understand that the Department of Human Services may recover for payments made by the Death Payments Program from the Veteran s Administration VA or the estate of the decedent. .

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