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Application for Assistance
Aubrielle’s Hope provides financial assistance for New Hampshire families with remembrance items or the funeral, burial and/or cremation for children five years old and younger within one year of a loss. These funds are for upfront costs and cannot be used for reimbursements. In order to apply for assistance, this completed form must be submitted to our Board of Directors for review. If approved, a representative from Aubrielle’s Hope will then contact the family to inform them of the assistance and will coordinate payment with the company mentioned on this application. The only thing we ask for in response of assistance is a short statement from the family acknowledging our help. Testimonials may be posted on our website and used by Aubrielle’s Hope to communicate how we are helping New Hampshire families facing the loss of a baby; fostering continued support for our mission. Anonymity is optional for families preferring to maintain their privacy.
The application for assistance must be submitted within one year of the loss of the child. Payment to the affiliated company must be made within one year of the loss of the child.
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Today's Date
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How did you hear about Aubrielle’s Hope?
Your answer
INFORMATION ON THE PERSON FILLING OUT THIS FORM:
Name:
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Relationship to Child:
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Phone Number:
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Email Address:
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INFORMATION ON THE CHILD:
Name of Child:
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Date of Birth
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Date of Death
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INFORMATION ON CUSTODIAL PARENTS:
Custodial Parent(s) Full Name
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Legal Address
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Mailing Address (if different)
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Home Phone Number
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Cell Phone
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Email
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INFORMATION ON FUNERAL HOME, CEMETERY, OR RELATED SERVICE:
Please provide the contact information of the Funeral Home, Cemetery or Related Service that you are asking for help with payment to. Attach the release of information sheet to show that the Funeral Home or Cemetery has permission to verify the information contained in this application. (Applications cannot be processed without verification by a staff member of the Funeral Home, Cemetery, or related buisness.)
Name of Funeral Home, Cemetery or Related Buisness
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Your answer
Name & Title of Contact Person
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Address
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Telephone
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Email
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At this time, the board is authorized to dispense $1,500 per child, please let us know how much money you are requesting (must be part of a funeral, burial, cremation, remembrance item, related service and/or associated fees):
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Please let us know what the amount you requested will be use for (must be part of a funeral, burial, cremation, remembrance item, related service and/or associated fees):
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Your answer
Aubrielle’s Hope’s assistance will be provided at the discretion of the Board of Directors and may only include assistance for remembrance items or the burial, cremation, or funeral of a child who passes away five years old or younger in New Hampshire. The board reserves the right to approve a portion of funds requested. Funds will be dispersed to businesses directly providing services. Approval is contingent upon complete and verifiable applications and available funds. We do not discriminate based on religion, race and sexual orientation.
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