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....
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How to fill out the HI DHS 1163 online
Filling out the HI DHS 1163 form is a crucial step in applying for the Death Payments Program in Hawaii. This guide provides clear and comprehensive instructions to assist you in completing the application accurately and effectively.
Follow the steps to complete the HI DHS 1163 form online.
- Click the ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering the decedent's information in section I. Provide the decedent's full name, sex, Social Security number, date of birth, and, if applicable, the VA file number for veterans.
- Proceed to section II. Here, you will need to fill in the date of death along with the applicant's information. Provide your full name, relationship to the decedent, Social Security number, and contact numbers (home/cell and work). Make sure to include your mailing address.
- In section III, indicate whether any full funeral benefits are available to the decedent by selecting 'Yes' or 'No'. These benefits may include pre-paid funeral plans or insurance plans.
- For section IV, state if anyone has received or expects to receive the lump-sum death payment benefit from Social Security for the decedent by selecting 'Yes' or 'No'.
- Review the certification statement carefully before signing. Ensure that the information provided is accurate to the best of your knowledge. The applicant must sign and date the application.
- After completing all sections, you can save the changes made to the form, then download, print, or share the application as needed.
Complete the HI DHS 1163 form online today to apply for the Death Payments Program.
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