Family Assistance Request Form

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)
Home Address(Required)

Victim and Crash Information

MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

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

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)

The Kailee Mills Foundation has limited funds available. Submitting this application does not guarantee assistance.

Subscribe to Our Newsletter