Ada Honor Program

Ada Honor Program Application
The Ada Honor Program is a way for CIRI to honor the lives of our deceased Shareholders and assists their families with the costs associated with a Shareholder’s death. Before completing this application, please note the following:
- The deceased individual must have been an active CIRI Shareholder who owned shares on their date of death.
- CIRI will only process one application for a deceased Shareholder.
- CIRI is unable to process applications that are incomplete; missing required documents; and/or untimely filed.
- If multiple applications are submitted, CIRI will process the first application received, unless another application is submitted from a person with higher priority within 10 business days of receiving the first application, provided CIRI has not already processed payment of the benefit for the first application. For information on priority, see Section 3.
- It is important that you carefully read each question and fully complete this application to allow CIRI to provide this benefit in a timely manner.
For your application to be considered on time, the completed application and supporting documents must be received by CIRI—or, if mailing, postmarked—within 180 days of the date of the Shareholder’s death to qualify for this benefit.
1. DECEASED SHAREHOLDER INFORMATION

Individual must have been an active CIRI Shareholder on the date of death
Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date of Death*

MonthDayYear
(dates of death prior to 1/1/2025 are ineligible)
2. APPLICANT INFORMATION
Name*

First NameMiddle NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Email*
Relationship*
Type of Relationship*
3. PRIORITY

Important information, please read carefully.
CIRI has established an order of priority for payment of this benefit. In relation to the deceased Shareholder, the following individuals/entities have priority to receive payment in the order listed:
1. Funeral Home/Crematorium, if a balance is due
2. Individual who has paid all or the majority of the Shareholder’s funeral/cremation expenses (if individuals paid equal amounts, funds will be paid to the first individual to submit a complete application and supporting document(s)
3. Spouse
4. Adult Child
5. Parent
6. Adult Sibling
7. Other Adult Members of Shareholder’s Family.
The individual with the highest priority shall have the right to direct CIRI regarding payment of this benefit, unless a balance is owed to a funeral home/crematorium, in which case payment will first go toward the existing funeral home/crematorium balance.
a. Has or will a Funeral Home/Crematorium provide services*

YesNoI don't know
Name of Business*
Business Phone Number*
Please enter a valid phone number. If not known, type "unknown".
Is there a balance currently owed to the Funeral Home/Crematorium?*

YesNo - Paid in Full
b. Is there an individual who has already paid for, or is liable for, funeral/cremation expenses*

YesNoI don't know
Individual’s Full Name*

First NameLast Name
Individual’s Phone Number*
Please enter a valid phone number. If not known, type "unknown".
Relationship to Deceased*
c. Does the Shareholder have a surviving spouse*

YesNoI don't know
Spouse’s Full Name*

First NameLast Name
Spouse’s Phone Number*
Please enter a valid phone number. If not known, type "unknown".
d. Does the Shareholder have any surviving adult children*

YesNoI don't know
List each adult child’s name and phone number. Click the '+Add Row' button to add another adult child if needed.*
e. Does the Shareholder have a surviving parent(s)*

YesNoI don't know
List the name(s) and phone number(s) of the parent(s). Click the '+Add Row' button to add another parent if needed.*
f. Does the Shareholder have any adult surviving siblings?*

YesNoI don't know
List each adult sibling’s name and phone number. Click the '+Add Row' button to add another adult sibling if needed.*
4. DOCUMENTATION
One or more of the following documents confirming the death of the Shareholder must be received before this application can be processed and the benefit can be paid.

Please indicate which document or documents are being provided by checking the appropriate box(es) below:
Documentation*

Death CertificateLetter/Invoice/Receipt from Funeral HomeMedical Record/Health Aide LetterCourt DocumentsBIA/Tribal DocumentsMilitary Service RecordPublished Obituary (Newspaper/Online)CIRI Obituary Form (Cannot be completed by the Applicant)News Article (Newspaper/Online)U.S. Find a GraveTrooper/Police/VPSO ReportOther (Please explain)
Documentation File Upload*

Multiple file uploads are allowed.
Cancelof
5. PAYMENT
Make check payable to: (You may only choose one of the options below. The individual with the highest priority shall have the right to direct CIRI regarding payment of this benefit, unless a balance is owed to a funeral home/crematorium, in which case payment will first go toward the existing funeral home/crematorium balance).
Make check payable to:*

Funeral Home/CrematoriumApplicantOther Individual
Name of Funeral Home/Crematorium or Other Individual*
Address*

Mailing Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Email
6. DISCLAIMERS & SIGNATURE

By signing this application, I certify, understand and agree to the following:
a. I am at least 18 years of age and the information provided in this application and any attachments thereto is true, accurate and complete, and I understand that any misrepresentations or inaccuracies may result in the need for me to repay the associated assistance funds.

b. CIRI, in its sole discretion, has the right to deny all incomplete applications, applications missing required documentation and applications filed outside of the 180-day period.

c. CIRI, in its sole discretion, has the right to contact and request additional documentation from me and others as needed to process this application, including contacting individuals/entities CIRI has designated with higher priority to receive the benefit.

d. CIRI shall process only one application and make only one payment on behalf of a deceased Shareholder. The only exception is when paying the full benefit directly to a funeral home/crematorium would exceed the costs of services provided; in this case, CIRI will issue a second check for the remaining benefit as directed by the applicant with the highest priority. Any amount paid to an individual must still be used for costs associated with, or reimbursement for, the Shareholder’s funeral, burial, cremation or cultural celebration expenses.

e. CIRI, in its sole discretion, may release the information contained in this application, including my name and contact information, to other interested parties inquiring into this benefit on behalf of the deceased Shareholder.

f. I fully release, indemnify and hold harmless CIRI from any and all claims and liability associated with this benefit, and I accept full responsibility for the proper use and distribution of the benefit payment.
By entering my name below, I agree to the submission of this application by electronic means and adopt my typed or electronically signed name as my legal signature.*

Yes
Applicant’s Signature*

Clear
Applicant’s Typed Signature*
Date*

MonthDayYear
Please verify*
Should be Empty:

Ada Honor Program Application

1. DECEASED SHAREHOLDER INFORMATION

2. APPLICANT INFORMATION

3. PRIORITY

4. DOCUMENTATION

5. PAYMENT

6. DISCLAIMERS & SIGNATURE