Family Assistance 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 Full Name of person completing this request form and relation to the victim(Required) Person completing this request form's phone number(Required) Person completing this request form's address(Required) Person completing this request form's email(Required) Name 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)(Required) MM slash DD slash YYYY Location of Crash(Required) 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)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) 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)CAPTCHA