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Life Interrupted Foundation
Application for Aid
First name
Last name
Email
Phone
Country/Region
Address
City
Zip / Postal code
Date of Loss
Month
What kind of help are you looking to receive?
Resources (i.e. support groups, lawyers, counselors, etc)
Essential Needs Grant
Grief Counseling Grant
Describe the Nature of the Loss
How will a Grant be used to help your situation?
Did you recieve any benefits (i.e. Life Insurance, 401k, etc) following the loss
Yes
No
Was the loss unexpected and/or sudden?
Yes
No
Death Certificate
Upload File
Most Recent Tax Return
Upload File
3 Most Recent Bank Statements
Upload File
Bills and/or Expenses
Upload File
Do you agree to a background check if conditionally approved for grant funding?
Yes
No
Signature
Clear
Submit
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