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Family Assistance Request Form

Family Assistance Request

I am authorized to provide the information within this request form because I am either: the parent/legal guardian of the affected person(s), the affected person, or have been authorized by the affected person or their parent/legal guardian.(Required)
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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 please give the funeral home permission to speak to us?(Required)

Counseling Information (if applicable)

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

Additional Information

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