Pre-Paid Funeral/Cremation VerificationPlease specify the amount for each category:1. Burial plot, gravesite, crypt, mausoleum, or niche1. Burial plot, gravesite, crypt, mausoleum, or niche(Required)2. Casket or urn2. Casket or urn(Required)3. Other repository customarily and traditionally used for the deceased’s bodily remains3. Other repository customarily and traditionally used for the deceased’s bodily remains(Required)4. Vaults or other burial containers4. Vaults or other burial containers(Required)5. Headstones, markers or plaques5. Headstones, markers or plaques(Required)6. Arrangements for the opening and closing of the gravesite6. Arrangements for the opening and closing of the gravesite(Required)7. Contract for the care and maintenance of gravesite (endowment)7. Contract for the care and maintenance of gravesite (endowment)(Required)TOTAL1TOTAL(Required)8. Transportation of body8. Transportation of body(Required)9. Embalming9. Embalming(Required)10. Cremation10. Cremation(Required)11. Flowers11. Flowers(Required)12. Clothing12. Clothing(Required)13. Services of funeral director and staff13. Services of funeral director and staff(Required)TOTAL2TOTAL(Required)All Contracts Must Be IrrevocableIs the headstone required to be purchased at the same time as the burial plot3?Is the headstone required to be purchased at the same time as the burial plot?(Required)YesNoIf purchased, will the headstone be carved (except for date) and be installed at the gravesite3?If purchased, will the headstone be carved (except for date) and be installed at the gravesite?(Required)YesNoN/AIf the value of items 8 through 13 are above the program limits, the contract must be purchased in the name of CPT AS TRUTEE FBO (CLIENT’S FULL NAME)If the value of items 8 through 13 are above the program limits, the contract must be purchased in the name of CPT AS TRUTEE FBO (CLIENT’S FULL NAME)(Required) 1Items 1 through 7 are excluded no matter the value 2Max value for items 8 through 13:SSI Recipients - $1,500Medicaid only - $1,800 3For Medicaid only recipients, the headstone is excluded if:It is required to be purchased at the time of the burial plot or,If it is not required to be purchased, the headstone must be carved (except for the date) and installed at the gravesiteΔ Download PDF
