Bereavement Assistance Application

Bereavement Assistance Application

If selected, you will be asked for documentation to support the data you provide. Likewise, all correspondences and award agreements will be generated from the personal information submitted below.
Criteria:

1. Has lost an immediate family member (Mother, Father, Brother, Sister, Husband, Wife, Son or Daughter) to gun violence.

2. Has lost a loved one within the past 6 months.

3. Must be located in Indiana or Georgia
Name*

First NameLast Name
Name (Parent/Guardian; if person listed above is 18 years or younger)

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
When did you lose your loved one?*

MonthDayYear
Date
Decedent's Name*

First NameLast Name
Decedent's relationship to you: *
How did you hear about us?*
If selected as a recipient, do you give us permission to share your story on our social media pages (FaceBook & Instagram)? (If yes, please upload a picture of the decedent below*

YesNo
Upload a picture of the decedent:

Cancelof
If selected as a recipient, how will the funds be used? *
Signature*

Clear
By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
Award decisions are made based on the availability of funds and number of applicants. All applicants considered will be notified of the final decision by the organization via email within 2-4 weeks. For those selected, funds will be sent to the applicant via Zelle, PayPal or CashApp. If you have any further inquiries, please feel to email us at: therkjfoundation@gmail.com.
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