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Legacies Live On Inc. Financial Assistance Application
Our sincerest condolences for your loss. Please fill out this form to apply for financial assistance from Legacies Live On Inc. Our financial assistance program provides short-term monetary support based on the immediate need(s) of the individual and/or family who has been impacted by the loss of a loved one.
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Email
*
Your answer
Phone Number
*
Your answer
Home Address (please include zip code, apartment number, etc.)
*
Your answer
Age (this is for the financial assistance recipient)
*
18-24
25-34
35-44
45-54
55-64
65 and over
Other:
Number of people in your household
*
Your answer
Number of dependents
*
0-1
2-3
4-5
More than 5
N/A
Age(s) of dependents (put n/a if you don't have dependents)
Your answer
Annual Income Level
*
Less than $20,000
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 and over
Other:
Please share which loved one has passed away (if multiple losses in a short period, please check all that apply)
*
Parent
Spouse
Child
Sibling
Friend
Relative
Other
Required
What was your loved one's name? Please provide their full name.
*
Your answer
What type of financial assistance do you require? (Please check your most important need)
*
Note: Our financial assistance program is short-term support at the moment. We provide stipends based on need of the individual and/or family.
Groceries & food
Household bills/expenses
Rent support
Clothing
School (i.e., purchasing supplies, books, etc.)
Other:
Please briefly explain why you need this financial assistance.
*
Your answer
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