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. Additionally, we are not able to support victims that were driving under the influence of drugs or alcohol. 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)

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)
Home Address(Required)

Victim and Crash Information

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
Max. file size: 32 MB.

Family Information

Financial Information

Has there been a significant change in household income due to the incident?(Required)
Has a GoFundMe been created?(Required)
Was there a life insurance policy on the deceased?(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)
Do you have vehicle insurance?(Required)
Will you please give the funeral home permission to speak to us?(Required)
Max. file size: 32 MB.
Do you have medical insurance to help cover these costs (if applicable)?(Required)

Counseling Information (if applicable)

Do you need assistance with grief counseling?
If so, do you have a pre-established counselor?

Additional Information

Do you give us consent to do a background check?(Required)
If financial assistance is provided, do you have an established bank account to receive funds?(Required)

Note: Due to limited funding, an emphasis is placed on vehicle crashes in Texas.

The Kailee Mills Foundation’s Family Assistance Program is a charitable initiative designed to provide financial support to families experiencing hardship due to injury or death resulting from a motor vehicle crash. We are not able to support incidents related to bicycles, motorcycles, pedestrians, or others that are not related to vehicle crashes. Additionally, we are not able to support victims that were driving under the influence of drugs or alcohol. All disbursements are subject to the sole and absolute discretion of the Foundation.

By submitting an application for assistance, applicants acknowledge and agree to the following:

• Submission of an application does not guarantee approval or distribution of funds.

• The Kailee Mills Foundation reserves the exclusive right to determine the recipients, amounts, timing, and terms of any financial assistance provided.

• The Foundation may approve, deny, increase, or decrease assistance amounts based on its own evaluation of need, available funds, and other relevant factors.

• The Foundation further reserves the right to refuse assistance to any applicant, at any time, for any reason, without the obligation to provide justification.

All decisions made by the Kailee Mills Foundation regarding Family Assistance Program applications are final and not subject to appeal or reconsideration.

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