Funeral Assistance Program application

About you

First name (legal name)

Last name

Date of birth

Phone

Home address

City

State

ZIP code

Email

How should we contact you?

Telephone Email Other

How?

Were you referred to us by a funeral home, hospital, hospice, or other organization?

Yes No

Referring organization: name and contact information

Information about the person who died

In this application, "you" are the person arranging, and financially responsible for, the funeral, burial, or cremation. The person who has died is "the Deceased".

Full name of the Deceased

Date of birth of the Deceased

Date of death

Your relationship to the Deceased

Are you responsible for paying the funeral, burial, or cremation expenses?

Yes No

Household and income

Number of people in your household (with you)

The other people in your household (who live with you and share expenses):

Name	Age	Relationship to you	Dependent

Your yearly gross income ($)

Total yearly gross household income ($)

Sources of household income

Other income

We compare household income with the Federal Poverty Guidelines published each year by the U.S. Department of Health and Human Services. Households at or below 300% of the guidelines ordinarily meet our income standard; between 300% and 400% may qualify because of other financial hardship; above 400% may be considered in exceptional circumstances involving substantial documented hardship.

Financial hardship

If your household income is above 300% of the guidelines, or your situation isn't reflected by your income, describe what significantly affects your ability to pay: loss of the Deceased's income, loss or reduction of your own income, other expenses related to the death, unusually high household expenses, or other significant financial obligations.

Available resources

Any significant financial resources reasonably available to you, including any assets of the Deceased, that could be used toward the funeral expenses.

Funeral arrangements

We do not require medical records or information about the cause of death. Please provide only information related to the funeral expenses.

The funeral, burial, or cremation arrangements that have been made or are planned

Date of service (or planned date)

Funeral home or other provider: name, address and telephone

Current status (tick all that apply)

Services have been completed. Services are scheduled. Arrangements have not yet been made. The funeral home requires payment before services can take place. A deposit has been paid. Other

Other

How urgent is it?

Why is help time-sensitive? (if relevant)

What happens if you don't get help?

A copy of the death certificate (or other proof of death) and the funeral home's itemized statement of goods and services are required. You will upload them in your account.

Funeral expenses

Type of assistance requested (tick all that apply)

Funeral home services Burial (cemetery plot, opening and closing of the grave, interment) Cremation Casket, urn, or grave marker Existing unpaid funeral bill

The funeral, burial, or cremation expenses you are asking help with:

Provider	Service or merchandise	Amount charged ($)	Balance due ($)

Amount of assistance you are asking us for ($)

The amount paid, if any, may be less than the amount requested and depends on available Program funds.

Your payment priority (optional)

If you have more than one expense, the order in which you would prefer us to apply any approved grant. We will try to honor it; every expense is still subject to verification and approval.

First priority

Second priority

Third priority

Insurance and other sources of payment

Did the Deceased have a life insurance or burial insurance policy?

Yes No I don't know

Insurance company

Policy number

Has a claim been submitted to the insurer?

Yes No Not applicable

Has the insurer paid the claim?

Yes No

Did the Deceased have a prepaid funeral or burial plan, or a cemetery plot that is already paid for?

Yes No I don't know

Please describe

Do insurance, a prepaid plan or benefits cover these costs?

Have you received, applied for, or do you expect payment or assistance for the same funeral expenses from any of these?

Other source

If applicable: which source

Amount received ($)

Amount expected ($)

Relationship to Wish Big Foundation

Are you, or was the Deceased, a director, officer, employee, substantial contributor, grant reviewer, or family member of any of these persons, or in any way affiliated with Wish Big Foundation, Inc.?

Yes No

Please describe the relationship

Disclosure of a relationship does not necessarily result in automatic disqualification. The Corporation will evaluate any potential conflict in accordance with its conflict-of-interest policies and applicable law, and any interested person shall not participate in the review or approval of the application.

Documents we will ask for

If we can take your application forward, you will upload these in your private account (you don't need them now):

Proof of identity (government-issued photo ID)
Proof of household income: your most recent federal income tax return, 2 recent pay stubs, or a benefits award letter
Death certificate or other proof of death
The funeral home's itemized statement of goods and services, contract, or invoice
Proof of your responsibility for the funeral expenses (for example, the funeral contract signed by you)
Signed Authorization for Disclosure of Funeral Billing Information (you sign it online in your account)
If applicable: life insurance or prepaid plan information, or a denial of a benefit claim

We do not ordinarily require complete medical records: please don't send medical information unrelated to the help requested.

Applicant certification

By signing below, I represent and certify that:

The information and documentation provided in this application are true, accurate, and complete to the best of my knowledge;
The funeral, burial, or cremation expenses for which I am requesting assistance are genuine obligations for which I am responsible in connection with the death of the Deceased;
I have disclosed applicable life insurance, prepaid funeral or burial plans, burial benefits, and other sources of payment that may pay, reimburse, reduce, or otherwise satisfy the funeral expenses for which assistance is requested;
I have disclosed any material financial assistance, insurance proceeds, governmental or burial benefits, estate assets, charitable assistance, or other payments already received or reasonably expected to be received with respect to the expenses for which assistance is requested;
I will promptly notify the Corporation of any material change in my financial circumstances, funeral expenses, insurance proceeds, outstanding balances, or other information that may affect my eligibility or the amount of assistance before payment of an approved Grant;
I have not knowingly submitted, and will not knowingly submit, the same funeral expense for duplicative payment or reimbursement from the Corporation and another source;
I have not knowingly omitted, concealed, or misrepresented information that would materially affect the Corporation's determination of eligibility or the amount of assistance; and
I understand that submitting this application does not guarantee assistance, and that approval of my application does not guarantee payment. Any payment will be made only if, and to the extent that, Program funds are available or become available, and I may receive partial payment or no payment. Any award is subject to the Corporation's eligibility requirements, verification procedures, available funding, and Funeral Assistance Program policies.
I authorize the Corporation to use the information contained in this application for purposes of evaluating and administering my request for charitable assistance. I understand that additional authorization may be required before a funeral home or other provider may disclose billing information directly to the Corporation.

Nature of assistance: the Corporation is not a funeral service provider

Please read each statement and tick the box to confirm that you understand and agree.

Not a funeral service provider. I understand that Wish Big Foundation, Inc. (the "Corporation") is a charitable organization that provides financial assistance only. It is not a funeral home, cemetery, crematory, or other funeral service provider. No arrangement of services. I understand that the Corporation does not arrange, select, or provide funeral, burial, or cremation services. All decisions about the arrangements remain solely between me and the providers I choose. No judgment of my arrangements. I understand that the Corporation's review of my application is an administrative and financial review only. A decision to approve, partially approve, defer, or deny assistance is not an opinion on the appropriateness of any arrangements, services, or provider. I remain responsible for the arrangements. I understand that I remain responsible for making arrangements with the funeral home or other provider, and for meeting any deadlines it sets, while my application is pending. Billing communications only. I understand that when the Corporation communicates with a funeral home, cemetery, crematory, or other provider on my behalf, it does so only about charges, balances, and payment arrangements. No responsibility for services received. I understand that any assistance is paid directly to the provider. That payment is not an endorsement of the provider or the services, and the Corporation is not responsible for the quality or timeliness of any services I receive. General resources only. I understand that any information the Corporation shares about outside programs, grants, or organizations is for general informational purposes only. I am responsible for contacting and applying to any such programs, and the Corporation does not guarantee their availability or results.

Signatures

By signing below, I confirm that I have read and understand this entire application, including the Corporation's Nature of Assistance statement and the Applicant Certification. I agree to all of the statements I have ticked and certified above.

Applicant: type your full name to sign

Authorized representative (complete only if someone is signing on the applicant's behalf)

Representative: type your full name to sign

Relationship to the applicant

Other relationship

We may ask for documentation of your authority (for example guardianship papers or a power of attorney).

I agree that typing my name above, or signing electronically, has the same legal effect as a handwritten signature.