Burial Payment Request Form 2026

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The document is a Burial Payment Request form used by the Department of Human Services in Pennsylvania. It outlines the process for requesting financial assistance for burial or cremation expenses, including details about the deceased, the requester’s relationship to the deceased, and any available assets that may affect payment eligibility. The form requires signatures from both the requester and a funeral director, certifying compliance with regulations and detailing costs associated with burial or cremation.

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Click ‘Get Form’ to open the Burial Payment Request form in our editor.
Begin by entering the Record Number and Social Security Number of the deceased in the designated fields.
Fill in the Name of Deceased, Age at Death, Date of Death, and Date of Request. Ensure all details are accurate for processing.
In the 'Request for Burial and/or Cremation Payment' section, indicate your relationship to the deceased by selecting from options such as Relative, Friend, or Other.
Provide any payments you will contribute towards burial expenses in the Payments Toward Burial section. List additional contributors if applicable.
Complete the Assets of the Deceased section by detailing available assets and their amounts.
Sign and date the form at the bottom to certify that all information is true and correct before submitting it through our platform.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (98 Votes)
2019	4.3 Satisfied (36 Votes)
2019	4.8 Satisfied (69 Votes)
2017	4.8 Satisfied (108 Votes)
2016	4.8 Satisfied (238 Votes)
2016	4.8 Satisfied (145 Votes)
2016	4.8 Satisfied (114 Votes)
2016	4.3 Satisfied (176 Votes)
2016	4.5 Satisfied (53 Votes)
2016	4.1 Satisfied (20 Votes)
2014	4.8 Satisfied (178 Votes)
2011	4.2 Satisfied (51 Votes)
2011	4.8 Satisfied (61 Votes)
2011	4.8 Satisfied (86 Votes)
2010	4.9 Satisfied (481 Votes)