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Effective Date: 



Updated: 10/1998


To provide a written statement that an asset has been designated for burial expenses.


When to Prepare

Complete Form H1252 when a client designates an asset for burial expenses. The client or responsible party signs the Form H1252. The beneficiary must also sign if cash value of insurance is designated.

Number of Copies

Complete an original and one copy.


The caseworker files the original in the case record and gives the copy to the client or his responsible party.

Form Retention

Form H1252 is kept permanently in the case record.