Bereavement Assistance form

Financial Assistance Grant
Instructions:
- This application must be filled out as completely as possible. Incomplete applications will be rejected.
Awarding of Grants:
- Applications award decisions will be determined as quickly as possible after it has been received.
- There is no guarantee of any assistance.
- Grant Policy Grants are paid to service providers only The child must be 12 months and younger, or stillborn Reimbursement of services already rendered cannot be granted.
Part 1:
Name of Applicant*

First NameLast Name
I am the point of contact for the family who will receive this grant*

YesNo
Name of Contact *

First NameLast Name
Relationship to Contact*

FamilyFriendOther
Applicant E-mail*
Applicant Phone Number*

Area CodePhone Number
Applicant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Part 2:
Child's Full Name*

First NameLast Name
Child's Age*
Date of Birth*

MonthDayYear
Date of Death*

MonthDayYear
Cause of Death*
Date of the Funeral

MonthDayYear
Burial Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Part 3:
Full Name of Parent One*

First NameLast Name
Full Name of Parent Two

First NameLast Name
Parent One's Occupation*
Parent Two's Occupation
Annual Gross Income*
Please tell us a little about yourself and what this assistance will be used for*
Part 4:
How did you hear about us?*

FamilyFriendsMedical Specialist / DoctorReligous / Spiritual LeaderOnline SearchOther
By applying for this grant you are certifying that all information is true. In the event The Luca John Foundation requires validation of annual income of the parents it must be made available otherwise the Grant Value will be rescinded. Should it be determined any information is untrue The Luca John Foundation will use all legal means to recover any funds granted.
Should be Empty:

Financial Assistance Grant

Part 1:

Part 2:

Part 3:

Part 4: