Unmarked Graves Application

Osage Nation Financial Assistance Department | Mailing 627 Grandview Ave Pawhuska, OK 74056 | Physical 239 W. 12th St Pawhuska, OK 74056
Office: 918.287.5325 | Email: financial-assist@osagenation-nsn.gov
UNMARKED GRAVES PROGRAM
The Osage Nation extends our sincere condolences for the loss of your loved one. To ensure the final resting place for Osage individuals are marked with a headstone, we are offering financial assistance. Assistance is available up to $2,200 for the purchase, delivery and installation of (1) headstone per unmarked grave. Reimbursements are prohibited. This program is temporary with limited funding and administered on first-come first-serve method.
Applications must include the following:
☐ Completed Unmarked Grave Application
☐ Copy of the estimate / invoice (from the monument company / vendor of your choice)
☐ Copy of vendor’s form W9 (for payment purposes)

Section I: Deceased Osage Individual
Name Name First Last
Middle Name
Date of Birth Date of Birth / MM / DD YYYY
Date of Death Date of Death / MM / DD YYYY
Osage Nation Membership Number (If Applicable)
Mother's Name Mother's Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Date of Death Date of Death / MM / DD YYYY
Father's Name Father's Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Date of Death Date of Death / MM / DD YYYY
Section II: Location of Grave
Cemetery Name
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Section #
Block #
Plot #
Section III: Vendor Information
Business
Amount Requesting $ Dollars . Cents
Mailing Address Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Website
Copy of the estimate / invoice (from the monument company / vendor of your choice)

Attach Files
Copy of vendor’s form W9 (for payment purposes)

Attach Files
Section IV: Applicant
Name Name First Last
Relation to the Deceased
Mailing Address Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Rights & Responsibilities

agree to allow the Osage Nation up to (10) business days to process the completed application and up to (20 business days to issue the payment. The undersigned hereby expressly recognizes that the benefit sought or presently enjoyed by the undersigned from the Osage Nation government, to wit: Osage Nation Financial Assistance is a privilege and a benefit to the undersigned and not a property interest or matter of right. In consideration of, and as a condition precedent to, the grant, issuance or continued enjoyment of this privilege and benefit, regardless of whether the undersigned is a natural or artificial person or entity, and further regardless of whether the undersigned is of Indian or non-Indian blood, descent or legal character, the undersigned hereby stipulates and agrees that jurisdiction over all matters and disputes arising out of exercise of such a benefit and privilege shall vest in the Osage Nation Trial Court. The undersigned further stipulates to be bound by all Osage Nation laws, codes, regulations, policies and procedures governing such benefits, privileges and activities. The undersigned further expressly waives all further rights to contest the jurisdiction of the Osage Nation Trial Court over any such matters, disputes, actions or decisions of any branch of the Osage Nation government.
The information contained within this Agreement and any supporting documentation attached is a protected record under the Osage Nation Open Records Act. The Osage Nation will not disclose any record containing protected information without the written consent of the applicant unless the information is being used to perform the duties of an Osage Nation employee. The application information will be released to update the Membership Department other Osage Nation Departments/Programs with which the applicant is receiving or requesting services and to the Office of the Osage Nation Attorney General for an investigation to detect or eliminate fraud.
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Full Name

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Date Date / MM / DD YYYY

Unmarked Graves Application

Unmarked Graves Application

Section I: Deceased Osage Individual

Section II: Location of Grave

Section III: Vendor Information

Section IV: Applicant

Rights & Responsibilities