APPPLICATION FOR BEREAVEMENT ASSISTANCE

APPPLICATION FOR BEREAVEMENT ASSISTANCE

(To be completed by the Family Coordinator)
Purpose:

The Gwich’in Tribal Council (GTC) is committed to supporting and improving the social well-being of the Gwich’in beneficiaries. The (GTC) Bereavement Assistance Program is intended for Gwich’in beneficiaries who require financial assistance in the event that there is:
- A death or imminent death of a beneficiary or an immediate family member of a beneficiary.
- A need for transportation of immediate family members to the funeral/and or community of the deceased or payment of other reasonable funeral related expenses as determined by the family coordinator.
Level of Support:
The Bereavement Assistance Program provides up to a maximum of $2,500 per family of the deceased.

Definition:

For the purpose of the Bereavement Assistance Program, the following definitions apply:
- “Gwich’in beneficiary” means an individual who is enrolled or is eligible to be enrolled in the Gwich’in
  Comprehensive Land Claim Agreement.
- “Immediate family member” includes: the spouse {including common-law), parents, parents-in-law,
  brothers, sisters, and children, including step, adoptive and foster children.
Family Coordinator:

At least 2 members of the immediate family will select one family member to serve as the family coordinator to request assistance from the Gwich’in Tribal Council. All requests to the Gwich’in Tribal Council must come directly from the family coordinator. Requests from other persons will be referred to the family coordinator.

Note:
A death certificate is required with this application. (Must apply within 6 months of death)
Family Coordinator
Family Coordinator Name*

First NameMiddle Name(s)Last Name
Enrolment Number
1234
Date of Birth

MonthDayYear
Date
Please provide either a Phone Number or Email Address (preferably both) so that we can contact you.
Phone Number*
Email*
example@example.com
Address
P.O. Box
Apt./Unit
Street No.*
Street Name*
City/Town*
Province/State*
Country*
Postal / Zip Code*
Family Members Agreement
Please provide name and signatures of two immediate family members to indicate agreement of Family Coordinator (Cannot be the Family Coordinator).
Name (immediate family member 1)*

First NameMiddle Name(s)Last Name
Name (immediate family member 2)*

First NameMiddle Name(s)Last Name
Signature of immediate family member 1*

Clear
Signature of immediate family member 2*

Clear
Information of Deceased
Full Name*

First NameMiddle Name(s)Last Name
Home Community
Enrolment Number
1234
Date of Passing*

MonthDayYear
Date
Date of Funeral*

MonthDayYear
Date
Location of Funeral*
Do you have the Death Certificate*

YES (upload copy below)NOPENDING
Upload Death Certificate

Cancelof
Banking Information
Name of Bank Account Holder*
Name of Bank*
Address of Bank & Location*
Institution #: *
Transit# (5 Digits)*
Account Number:*
Family Coordinator Signature
Signature*

Clear
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty: