I confirm that I am the legal parent/guardian/ or next of kin or have permission to apply on behalf of the deceased.*

I declare that there is no life insurace, inheritance, or significant savings available to cover the the cost of a funeral, cremation, or memorial expenses for my loved one. *

I understand that submission of this application does not guarantee assistance and that all information I provide will be verified. *

I certify that all information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that providing false or misleading information may result in denial of assistance. *