The Connor Kirby Infant Memorial Foundation

If you need Financial Assistance...

Effective June 23rd, 2008 the Board of Directors approved to change some of our policies. Effective the same date, only residents from the states of Pennsylvania and Maryland can be eligible to receive assistance from our charity. Our new Proof of Residency Policy states that every applicant must submit to us a copy of one of the following: a copy of your most recent utility bill (no more than 60 days old), a copy of your most recent mortgage statement (no more than 60 days old), or a copy of the first page of your most recent tax return (page 1 of your Form 1040, with your social security number blacked out). Any applicants that have applied for assistance that are not residents of Pennsylvania or Maryland who applied before June 23rd, 2008 will be grandfathered in for assistance. If you should have any questions, please contact Adele Kirby adele@ConnorKirbyMemorial.org.

We know that it is THE most difficult thing in the world to lose your child. So, if you are in need of financial assistance for funeral or cemetery costs, or for therapy sessions, please fill out the following questionnaire.

If you would prefer to have the application faxed to you, please call us at (717) 530-0559.

Please note: Financial Assistance can only be given for outstanding balances for funeral, burial or cremation, cemetery costs, and grave marker costs. After submitting the Financial Assistance Form, you will be contacted within 7-10 days. We will also need copies of your outstanding bills sent to us within 90 days.

	Funeral Expense	$300
	Cremation Expense	$300
	Cemetery Expense	$100
	Grave Marker Expense	$350
	Family Therapy Support	$800

First Name

* Required

Last Name

* Required

Spouse's First Name

* Required

Spouse's Last Name

* Required

Street Address

City

State

Zip Code

Phone Number

* Required

Email Address

* Required

How did you hear about The Connor Kirby Infant Memorial Foundation?

Your Date of Birth

(xxxx)

Do you and your family have health insurance coverage?

Yes No

If answered yes, the Insurance Benefits Information Release must be signed by the policy holder and sent in before we can access your information in order to assist you.

Are you currently receiving any financial assistance?

Yes No

If answered yes, please explain

What kind of assistance are you currently in need of and applying for?
Please check all that apply

Funeral Expense

Cemetery Expense

Grave Marker Expense

Family Support - Therapy Sessions

If known, please provide us with your funeral arrangements / information, please include dates and types.

Please provide the name, address & contact person of the funeral home you are using, if known.

Child's Full Name

Child's Date of Birth

(xxxx)

Child's Date of Passing

(xxxx)

Please provide us with a brief history about you, your family and the loss of your infant. This information will be kept confidential and will aid our organization in our decision making as well as provide us with more statistics for future funding.