Low-Income Funeral Assistance Request Form
Applicant Information
Full Name
Address
Phone Number
Email Address
Deceased Information
Full Name of Deceased
Relationship to Applicant
Date of Death
Financial Information
Monthly Household Income
Number of People in Household
Are you receiving any other funeral assistance? If yes, please specify.
Funeral Details
Funeral Home Name
Estimated Funeral Cost
Assistance Amount Requested
Additional Information