BURIAL ASSISTANCE APPLICATION | www.kawnation.gov

Tribal Membership Card of Deceased

No file chosen

Attach a copy of deceased membership card showing enrollment number.

Deceased Kaw Member Enrollment Number *

Copy of Death Certificate *

No file chosen

Attach a copy of deceased membership card showing enrollment number.

Name of Deceased *

Maiden Name if Applicable

Date of Death *

Degree of Kaw Blood

Birthdate of Deceased: *

Last Known Address of Deceased *

Date of Funeral *

Name & Address of Funeral Home *

COPY OF INVOICE SHOWING COST OF FUNERAL EXPENSES *

No file chosen

Attach invoice here

COPY OF FUNERAL HOME'S W-9 (IF AVAILABLE)

No file chosen

Attach W-9 here

Next of Kin Completing Application *

Relationship to Deceased *

Address *

Phone

I certify that I am an enrolled citizen of the Kaw Nation and that I am not enrolled with another tribe. I understand that dual enrollment is not allowed and that if evidence of such is found, this application will be void and I will be denied services. I also understand that if evidence of dual enrollment is found after services are received, that legal action may be taken to recover any benefits awarded. *

Applicant Signature

Date *