ESTATE RECOVERY PROGRAM
NOTIFICATION OF DEATH

THE FOLLOWING INFORMATION MUST BE COMPLETED BY THE NURSING FACILITY OR OTHER FACILITY RETURNED TO THE DEPARTMENT OF SOCIAL SERVICES WITHIN 15 DAYS OF THE DATE OF DEATH.










PLEASE ANSWER ALL THE FOLLOWING:
DOES THE DECEASED HAVE A:
  (1) Surviving Spouse
  (2) Surviving Minor Children
  (3) Surviving Disabled Children

PLEASE LIST BELOW THE NAME, MAILING ADDRESS, AND RELATIONSHIP OF CONTACT PERSON:




  (4) WILL
 
 

  (5) PRE PAID BURIAL FUND - REVOCABLE OR IRREVOCABLE BURIAL TRUST

                                                      
 

FINAL TRUST FUND RECONCILIATION
 
AMOUNT IN PERSONAL TRUST ACCOUNT ON DATE OF DEATH
 
ADD DEPOSITS AND/OR CREDIT BALANCES
 
SUB TOTAL OF TRUST FUND
LESS FINAL EXPENSES PAID FROM PERSONAL TRUST FUND (ATTACH COPY OF CHARGES AND PROOF OF PAYMENT)
 
FUNERAL COSTS
 
HEADSTONE COST
 
CREMATORIUM COST
 
OTHER - PLEASE LIST:
 
 
 
 
 
 
TOTAL FINAL EXPENSES PAID
     
 
BALANCE FOR DSS:


(IN ACCORDANCE WITH SDCL 29A-3-817 AND SDCL34-12-38 )

IF THERE IS A SURVIVING SPOUSE THERE IS NO RECOVERY BY DSS IF FUNERAL EXPENSES HAVE BEEN PAID THE BALANCE MAY BE SENT IN.


COMPLETED BY:



 


 


 


 


 


   
RETURN THIS FORM TO: DEPARTMENT OF SOCIAL SERVICES
OFFICE OF RECOVERIES AND FRAUD INVESTIGATIONS
ESTATE RECOVERY PROGRAM
700 GOVERNORS DRIVE
PIERRE SOUTH DAKOTA 57501-2291
   
FOR INFORMATION CONTACT: ESTATE RECOVERY PROGRAM AT 605-773-3653


The Facility must also notify the local eligibility caseworker of the death of a Medicaid recipient.