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This legal form is specifically designed for cases where an official death certificate for an employee cannot be obtained within the state of Arkansas. The affidavit requires comprehensive identification of the deceased employee, including member details, dates, and organizational affiliation, alongside contact information for the Human Resources (HR) representative. By completing and signing this document, the HR contact certifies the accuracy of the provided information, authorizing its use in the processing of ARBenefits Plan coverage. The form must be submitted to the EBD via a dedicated task system or by fax to 501-682-1200, ensuring proper administrative compliance and benefit management during the transition period following an employee's passing. This document serves as a verified record for personnel benefits administration when standard vital records are unavailable.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/affidavit-for-notice-of-death-arkansas-employee-benefits-division/284125/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/affidavit-for-notice-of-death-arkansas-employee-benefits-division/284125.png","ImageObject",442,249,{"name":88,"@type":89},"Cart","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-24","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",6,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"In what situation should this affidavit be used?","Question",{"text":109,"@type":110},"This affidavit is used only for Arkansas employees when a formal death certificate cannot be obtained.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How should the completed form be submitted to the EBD?",{"text":114,"@type":110},"The form should be submitted via a task in the system assigned to the Eligibility group or faxed to 501-682-1200.",{"name":116,"@type":107,"acceptedAnswer":117},"Does this form apply to an employee's family members?",{"text":118,"@type":110},"No, this affidavit only applies to the employee and not to members of their family.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},284125,1791069826,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},18829141979164,"https://eur-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Affidavit for Notice of Death  \nThis Affidavit for Notice of Death only applies to your employee and not the members of their family. This Affidavit can only be used for employees within the State of Arkansas, where a Death Certificate cannot be obtained. For out-of-state employees, EBD requires a copy of the Death Certificate.  \nComplete this form and return to EBD via a Task and assign to the Eligibility group or fax to  \n501-682-1200.  \nDeceaseD InformatIon  \n\n| Last Name |  | First Name |  |  |  | Date of Birth |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Member Number | Date of Death |  |  | Agency/School District |  |  |  |\n| Street Address |  |  | City |  | State |  | Zip Code |\n\nHI r contact InformatIon  \n\n| Last Name |  | First Name |  |  |\n| --- | --- | --- | --- | --- |\n| Street Address | City |  | State | Zip Code |\n| Phone Number | Email Address |  |  |  |\n\nBy signing this affidavit I certify that the information provided above is accurate. I understand that any misrepresentations in the information I provided above will be subject to penalty. If applicable, I authorize the release of the information noted above and agree to its use in the application process for  \nARBenefits Plan coverage .  \nHIR Signature:    \nDate:    \nMAIL OR FAX FORM TO:  \nDepartment of Transformation and Shared Services-Employee Benefits Division PO Box 15610, Little Rock, AR 72231-5610-FAX: 501-682-1200","cbCaiutS6W1KemBK","https://ap.wps.com/l/cbCaiutS6W1KemBK","pdf",555900,"English","# Deceased Information\n## HR Contact Information\n## Certification and Submission","[{\"question\":\"In what situation should this affidavit be used?\",\"answer\":\"This affidavit is used only for Arkansas employees when a formal death certificate cannot be obtained.\"},{\"question\":\"How should the completed form be submitted to the EBD?\",\"answer\":\"The form should be submitted via a task in the system assigned to the Eligibility group or faxed to 501-682-1200.\"},{\"question\":\"Does this form apply to an employee's family members?\",\"answer\":\"No, this affidavit only applies to the employee and not to members of their family.\"}]","Affidavit for Notice of Death - Arkansas Employee Benefits Division | PDF",1789628260]