Family Assistance Request Form: Vehicle Crashes Only

At the Kailee Mills Foundation, our mission is focused on providing support to families affected by vehicle crashes only. Due to limited funding, we currently place an emphasis on vehicle crashes in Texas. We recognize that there are many worthy causes and needs. If your current situation does not directly relate to the aftermath of a vehicle crash, we regret to inform you that you are not be eligible for our specific programs. We are not able to support incidents related to bicycles, motorcycles, pedestrians, or others that are not related to vehicle crashes. Thank you again for your understanding, and we wish you the best in finding the appropriate support for your situation.

Family Assistance Request (Vehicle Crashes Only)

Was this a result of a vehicle crash? Note: if this was a pedestrian, bicycle, motorcycle, or any unrelated incident, please do not complete this form.(Required)

Yes (you may continue with the form)

No (please do not complete this form)

Your Information (Person Making The Request)

I am authorized to provide the information within this request form because I am either: the parent/legal guardian or Spouse/ Partner of the affected person(s), the affected person, or have been authorized by the affected person or their parent/legal guardian.(Required)

Yes

First Name(Required)

Last Name(Required)

Your relation to the victim(Required)

Phone Number(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email Address(Required)

A Link to Your Facebook or Instagram(Required)

Victim and Crash Information

Name of injured or deceased(Required)

Full address of injured or deceased (address, city, state, zip)(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Date of Crash(Required)

MM slash DD slash YYYY

Date of Death (if applicable)

MM slash DD slash YYYY

Location of Crash(Required)

Law Enforcement Agency At Crash (in known)(Required)

Details of Crash (please include as much information as possible.(Required)

Please upload the police report if available.

Max. file size: 32 MB.

News Article with Details of the Crash (If applicable)(Required)

Family Information

Mother or Legal Guardian of the Victim Full Name(Required)

Mother or Legal Guardian of the Victim Full Home Address (address, city, state, zip)(Required)

Mother or Legal Guardian of the Victim Phone Number(Required)

Mother or Legal Guardian of the Victim Email Address(Required)

Marital Status(Required)

Additional notes or comments about familial relationship(Required)

Father or Legal Guardian of the Victim Full Name(Required)

Father or Legal Guardian of the Victim Home Address(Required)

Father or Legal Guardian of the Victim Phone Number(Required)

Father or Legal Guardian of the Victim Email Address(Required)

Marital Status(Required)

Additional notes or comments about familial relationship(Required)

Please enter the name(s) of person who is responsible for paying the cost resulting from this incident(Required)

Financial Information

Annual Household Income of person(s) responsible for costs resulting from this incident (range is fine)(Required)

Additonal Notes or Comments regarding income of the responsible parties(Required)

Has there been a significant change in household income due to the incident?(Required)

Yes

If yes, please explain.(Required)

Has a GoFundMe been created?(Required)

Yes

GoFundMe Link(Required)

Was there a life insurance policy on the deceased?(Required)

Yes

N/A

Life Insurance Amount (list "n/a" if not applicable)(Required)

Will you receive an insurance settlement as a result of this crash? Yes or No(Required)

Will you receive an insurance settlement as a result of this crash? This could be legal or auto (your insurance or someone else's).(Required)

Yes

Not sure

Please explain in as much detail as possible.(Required)

If yes, what is the estimated amount?(Required)

Funeral Costs (list "n/a" if not applicable)(Required)

Funeral Home Name (list "n/a" if not applicable)(Required)

Will you please give the funeral home permission to speak to us?(Required)

Yes

N/A

Please upload the funeral home invoice or estimate (if applicable).

Max. file size: 32 MB.

Do you have medical insurance to help cover these costs (if applicable)?(Required)

Yes

N/A

Medical Costs- Deductible- Out of Pocket Max Owed (list "n/a" if not applicable)(Required)

Are you receiving financial support from any other organizations? If so, please list them here along with the amounts.(Required)

Have you requested financial support from any other organizations? If so, please list them here.(Required)

Counseling Information (if applicable)

Do you need assistance with grief counseling?

Yes

If so, do you have a pre-established counselor?

Yes

If so, please list their name and contact information.

Additional Information

How did you hear about the Kailee Mills Foundation?(Required)

If there are any other expenses or items, or questions you have, please list them here.(Required)

Do you give us consent to do a background check?(Required)

Yes

If financial assistance is provided, do you have an established bank account to receive funds?(Required)

Yes

The Kailee Mills Foundation has limited funds available. Submitting this application does not guarantee assistance. All applications undergo a review process. Due to limited funding, an emphasis is placed on vehicle crashes in Texas.

Family Assistance Request Form: Vehicle Crashes Only

Family Assistance Request (Vehicle Crashes Only)

Your Information (Person Making The Request)

Victim and Crash Information

Family Information

Financial Information

Counseling Information (if applicable)

Additional Information

Events

Our Impact

take action

Subscribe to Our Newsletter

Family Assistance Request Form: Vehicle Crashes Only

Family Assistance Request (Vehicle Crashes Only)

Your Information (Person Making The Request)

Victim and Crash Information

Family Information

Financial Information

Counseling Information (if applicable)

Additional Information

Events

Our Impact

take action

Subscribe to Our Newsletter

Get Your Seat Belt Ribbon Decals