Death Benefit Request Form — https://ottawatribe.gov/

Death Benefits Request Form

The Ottawa Tribe provides a death benefit to help with the funeral expenses of Tribal Members and their spouses (including widows and widowers). The benefit is meant to help offset or reimburse the cost. Please read below to see what documentation is required with the request.

DEATH CERTIFICATE MUST BE SENT TO ADAWE.OTO@GMAIL.COM ONCE THE REQUEST FORM TO RECEIVE BENEFITS HAS BEEN COMPLETED.

REQUEST FORM MUST BE SUBMITTED WITHIN 90 DAYS OF THE DEATH DATE.

(Exceptions may be made due to medical examiner delay)

Name of Deceased

First Name

Last Name

Date of Death

MM

DD

YYYY

Roll Number

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Request Made By

First Name

Last Name

Relation to Deceased

Check One: Benefits Paid To:

Funeral Home

Family Member

Other

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

If the benefit is paid to the funeral home, no documentation is required EXCEPT DEATH CERTIFICATE. If payment is paid to a family member or other person, a copy of the receipt showing responsibility for funeral cost or copy of Power of Attorney much be sent to adawe.oto@gmail.com.

PLEASE SELECT DOCUMENTS THAT WILL BE PROVIDED:

Receipt

Power of Attorney

Death Benefits Request Form

Questions? Call us at (918) 540-1536 or reach us at adawe.oto@gmail.com

Form can also be downloaded and faxed to (918) 542-3214.

Ottawa Tribe of Oklahoma

Information