Financial Assistance Form

Child's Full Name
Child's Birth Date	mm/dd/yyyy
Child's Death Date	mm/dd/yyyy
Mother's Full Name
Father's Full Name
Address
Phone	123-555-1234
Name of Contact Person If other than Parents

Funeral/Burial

Funeral Home
Address
Phone	123-555-1234
Funeral Director
Amount Requested	$USD

Cremation

Crematorium
Address
Phone	123-555-1234
Contact Person
Amount Requested	$USD

Cemetery

Cemetery Name
Address
Phone	123-555-1234
Amount Requested	$USD

Headstone

Company Name
Address
Phone	123-555-1234
Amount Requested	$USD

Brief History of your Child

Do you currently have health insurance?

Are you going to be receiving benefits from a current life insurance policy?

By clicking submit, I authorize the Olivia Raine Foundation and its representatives to discuss with the providers listed above my financial obligation to these providers.