Page 1684

West Virginia Income Maintenance Manual Chapter 20

West Virginia Income Maintenance Manual Page 49 Chapter 20 Emergency and Special Assistance Programs

20.3.8.A.1 Instructions for Completing Form DFA-BU-3 The Financial Clerk will complete the DFA-BU-3 form on all cases. The Affidavit of Burial Costs is a form letter and is completed as follows: ➢ Introductory Statement The Financial Clerk will enter the name and address of the County Clerk. The name of the deceased and the amount of the claim is entered in the spaces provided. The amount of the claim cannot exceed $1,000. ➢ Affidavit and Verification The affidavit and verification process include the following: • The Financial Clerk enters his name, the amount of the claim against the deceased's estate, and the name of the deceased in the spaces on the form. • The Financial Clerk signs his name in the "Affiant" space and obtains the signature of the Notary Public. • The DFA-BU-3, plus a copy of the DFA-67-A, Burial Billing Form, is attached to the Monthly Burial Report and submitted to the Office of the County Clerk. 20.3.8.B Reimbursement from the Deceased’s Estate When the Financial Clerk receives reimbursement from the deceased's estate for the amount of the burial costs paid by the DOHS, he will make a direct deposit of this reimbursement to the burial program for the fiscal year in which the burial was paid. 20.3.8.C Release of Lien against Estate Following deposit of the reimbursement check from the deceased’s estate for the amount of the burial costs paid by the DOHS, the Financial Clerk will forward a copy of a lien release packet. The lien release packet consists of the following: • A copy of the DFA-67-A;

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Page 1684

Official source

West Virginia Income Maintenance Manual Chapter 20

West Virginia Income Maintenance Manual Page 49 Chapter 20 Emergency and Special Assistance Programs

20.3.8.A.1 Instructions for Completing Form DFA-BU-3 The Financial Clerk will complete the DFA-BU-3 form on all cases. The Affidavit of Burial Costs is a form letter and is completed as follows: ➢ Introductory Statement The Financial Clerk will enter the name and address of the County Clerk. The name of the deceased and the amount of the claim is entered in the spaces provided. The amount of the claim cannot exceed $1,000. ➢ Affidavit and Verification The affidavit and verification process include the following: • The Financial Clerk enters his name, the amount of the claim against the deceased's estate, and the name of the deceased in the spaces on the form. • The Financial Clerk signs his name in the "Affiant" space and obtains the signature of the Notary Public. • The DFA-BU-3, plus a copy of the DFA-67-A, Burial Billing Form, is attached to the Monthly Burial Report and submitted to the Office of the County Clerk. 20.3.8.B Reimbursement from the Deceased’s Estate When the Financial Clerk receives reimbursement from the deceased's estate for the amount of the burial costs paid by the DOHS, he will make a direct deposit of this reimbursement to the burial program for the fiscal year in which the burial was paid. 20.3.8.C Release of Lien against Estate Following deposit of the reimbursement check from the deceased’s estate for the amount of the burial costs paid by the DOHS, the Financial Clerk will forward a copy of a lien release packet. The lien release packet consists of the following: • A copy of the DFA-67-A;