Application for Assistance

Application for Assistance

We are deeply sorry that you have come to find our organizatin whether it is by your own loss or the loss of someone near to you. If you are the parent of a stillborn baby in Tennessee, please complete this form to apply for assistance for burial/cremation. Submit prior to or within 30 days of services. All information will be kept confidential.
Before completing an application for assistance, please make sure you meet the following requirements:
- Due to our 501(c)3 status, baby must be stillborn at 20 weeks gestation or after
- Must be a resident in the state of Tennessee with services to be performed in Tennessee
- Byron C. Glenn III Foundation offers assistance up to $1,000 towards the cost of burial services, which may include grave markers.
- Byron C. Glenn III Foundation offers assistance up to $500 towards the cost of cremation services, which may include cremation container/urns.
- Must have an outsanding balance.*
*Funds will only be distributed to the service provider (e.g. funeral home or cemetery) directly. Funds will not be given directly to family members. Balance must be current. We are unable to reimburse families for previously paid expenses.

The amount of financial assistance does not exceed $1,000.
Today’s Date

MonthDayYear
Date
Date of Services

MonthDayYear
Date
Baby’s Full Name
Gender
Birth date

MonthDayYear
Date
Was baby stillborn?
Weeks of Gestation
Baby must be stillborn on or after 20 weeks gestation.
Was baby a multiple?
Full name of sibling
If baby was a multiple, was sibling also stillborn?
If baby was a multiple, will they be burired/cremated together or separately?
Mother’s Full Name
Mother’s Email
example@example.com
Mother's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mother’s Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Father’s Full Name (if applicable)
Father’s Email
example@example.com
Father's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Father’s Address (if same write 'same')

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
I verify that all of the above information is true
Name of Funeral Home
Funeral Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Funeral Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Name of Funeral Director
Service Type
Amount Requested
Amount of assistance does not exceed $1,000.
How did you hear about us?
Byron C. Glenn III Foundation's purpose is to help ease the unexpected financial burden families face when determining the final resting place for their forever baby.

Submission of application is not a guarantee of assistance. All applications are submitted to our board and finance director for review of available funds.

www.BCG3Foundation.org

EIN: 83-1413008
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