Financial Assistance Form

Personal Information

Baby's Full Name
Baby's Birth Date	mm/dd/yyyy
Baby's Death Date	mm/dd/yyyy

Mother's Full Name
Mother's Address
Mother's City, State, and Zip
Mother's Phone	123-555-1234
Mother's Email

Father's Full Name
Father's Address
Father's City, State, and Zip
Father's Phone	123-555-1234
Father's Email

Financial Information

Mother's Annual Income
Mother's Employer
Mother's Employer's Address
Mother's Employer's Phone	123-555-1234

Father's Annual Income
Father's Employer
Father's Employer's Address
Father's Employer's Phone	123-555-1234

Funeral/Burial

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

Cemetery

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

Cremation

Crematorium
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?

How did you hear about the Olivia Raine Foundation?

Are you receiving assistance through another organization?

If yes, what organization and amount receiving from organization:

Does the Olivia Raine Foundation have permission to post you and
your child's names on our website and any written publication?

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.