Family Assistance Request 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 No First Name(Required) Last Name(Required) Your relation to the victim(Required) N/A Phone Number(Required)Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country N/A Email Address(Required) N/A Victim and Crash InformationName of injured or deceased(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) Details of Crash(Required)Family InformationMother or Legal Guardian of the Victim Full Name(Required) Mother or Legal Guardian of the Victim Home Address(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) Home address of injured or deceased (if different)(Required) Please enter the name(s) of person who is responsible for paying the cost resulting from this incident(Required) Financial InformationHousehold 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 No Please explainHas a GoFundMe been created?(Required) Yes No GoFundMe Link Was there a life insurance policy on the deceased?(Required) Yes No 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) If so, what is the estimated amount? (list "n/a' if not applicable)(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 No N/A Medical Costs- Deductible- Out of Pocket Max Owed (list "n/a" if not applicable)(Required) Do you have medical insurance to help cover these costs (if applicable)(Required) Are you receiving financial support from any other organizations? If so, please list them here along with the amounts.(Required) Counseling Information (if applicable)Do you need assistance with grief counseling? Yes No If so, do you have a pre-established counselor? Yes No If so, please list their name and contact information. Additional InformationHow 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 No If financial assistance is provided, do you have an established bank account to receive funds?(Required) Yes No The Kailee Mills Foundation has limited funds available. Submitting this application does not guarantee assistance.
