Funeral and Other Related Burial Expenses Application

Funeral and Other Related Burial Expenses Application 1. Application for Payment of Funeral and Other Related Burial Expenses (Form DB-030) should be completed in part by the deceased individual’s next of kin and in part by the chief law enforcement officer or public agency director and sent by the Employer to the Mississippi Department of Public Safety along with the requested documents. 2. The following documents must be included with Form DB-020 at the time of submission: a. Copy of a contract for services or invoice for services rendered; b. Completed W-9 for company/funeral home if a direct payment is being issued; c. An attested copy of the covered employer’s record showing deceased’s date of hire or membership; and d. If a volunteer, proof of the deceased’s service as an active part-time or on-call member of the department within the six months prior to death. 3. The submission of Form DB-030 does not guarantee payment under MCA §45-2-1. Payment is subject to the availability of funds, and the Mississippi Department of Public Safety makes the final determination of payment under the statute. 4. The Funeral and Burial Payment Request Form (Form DB-030) should be completed by the chief law enforcement officer or public agency director, as “Employer” for the deceased individual. This form shall be completed upon request of the covered individual’s next of kin and submitted to MDPS, along with (1) a copy of the contract for services or invoice for services rendered and (2) a completed W-9 for the company or funeral home if a direct payment is to be issued. 5. Submission of the Funeral and Other Related Burial Expenses Application should be made by the Employer and filed with the Legal Division of the Mississippi Department of Public Safety at Post Office Box 958 in Jackson, Mississippi 39205. Questions or concerns should be directed to DeathBenefitsTrust@dps.ms.gov.