Weeping Willa Grant Request Form

Weeping Willa Grant Request Form

We are here for you, we are here with you, we are you. Please let us know how we can best support you.
All applications are reviewed every month by board members. After decisions have been made, checks will be mailed out to applicants who have been approved for the Weeping Willa Grant. Not all applicants will receive financial support. Detailed background checks with valid references and proof of hardship are required to be eligible for a Weeping Willa Grant.
NAME OF REQUESTOR:*

First NameLast Name
MOTHER'S NAME:*

First NameLast Name
Mother's Driver's License/ID

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FATHER'S NAME:

First NameLast Name
Father's Driver's License/ID

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HOME ADDRESS: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Proof of Residency

Bill with name and address; can be a utility bill, credit card statement, or lease agreement, etc.
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REQUESTOR EMAIL: *
example@example.com
REQUESTOR PHONE NUMBER:*
Please enter a valid phone number.
WHAT TYPE OF LOSS HAVE YOU ENDURED?*

MiscarriageTFMRStillbirthInfant LossChild LossLoss to SuicideLoss to OverdoseOther
IF OTHER, PLEASE EXPLAIN:
REFERENCES:

For verification of information, please provide at least 2 references who can vouch for applicants situation. These are required to be completed in order to process a grant.
First & Last Name of Reference Person 1:*
Phone Number*
Please enter a valid phone number.
First & Last Name of Reference Person 2:*
Phone Number*
Please enter a valid phone number.
First & Last Name of Reference Person 3:
Phone Number
Please enter a valid phone number.
AMOUNT OF GRANT

A grant up to $1000 may be awarded for any expenses that may have incurred with the loss of a child. These grants may be used at your discretion. Only one grant per year will be allotted per family.
REASONS FOR PERSUING FINANCIAL ASSISTANCE (select all that apply)*

I am not currently employedMy spouse is not currently employedMy family is unable to assist with costsFinancial hardshipI have applied for public aide assistance but am not eligible
IF FINANCIAL HARDSHIP, PLEASE EXPLAIN:
Proof of financial hardship, medical bills or any other pertinent documents are required to be considered for grant. *

If this is not completed your application will not be processed.
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HOW CAN WE BEST HELP YOU DURING THIS TIME? *
I certify that the facts stated in this application are true and correct. If the information is not accurate, I understand that I may be subject to revocation of all grant monies awarded.:*

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If you would like to share your story, please do so here. We also have a virtual honor wall on our website where we pay tribute to your angel(s). You may also upload an image below to have shared online. We are grateful and honored to be a safe platform to share your child in the stars amongst fellow loss families.
www.weepingwilla.org/honor-wall
Please visit our website at www.WeepingWilla.org

Transforming grief to growth
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Weeping Willa Grant Request Form

REFERENCES:

AMOUNT OF GRANT

Please visit our website at www.WeepingWilla.org