Cremation and Funeral Financial Assistance Program HiddenNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.Request for Cremation or Funeral Financial AssistanceThis form contains conditional logic, so the options you see will update based on certain selections. Our Cremation or Funeral Financial Assistance Program is limited by our available funds. If you would like to check for funds availability before submitting the from, please contact us. We will try to update this page when funds are not available. Was the mother or baby a patient at MUSC or Roper St. Francis Healthcare when the stillbirth (intrauterine fetal demise 20+ weeks) or neonatal demise (within the first week of life) occurred?(Required) Yes-MUSC Yes-Roper St. Francis Healthcare No Not Eligible for this FormAt this time, our online form is limited to MUSC and Roper St. Francis Healthcare referred patients only. Please contact us for program available. Our program is limited to SC residents and SC hospitals.MUSC Referral - Shortened FormThis is our MUSC Referral shortened form that does not require financial information. MUSC’s approved Financial Assistance Form must be submitted or emailed by a MUSC employee. Person Submittng the FormOur preference is for one of the parents to submit the form, but we know the grieving process is difficult. We understand if a trusted individual is helping the parents during this difficult time. We encourage this type of support to the parents. However, we must contact one of the parent's to verify funding details.Person is submitting the form is:(Required)Parent of BabyFamily MemberFriendMUSC EmployeeRoper St. Francis Healthcare EmployeeOtherYour Name(Required) First Last Organization(Required) Title(Required) Phone(Required)Email(Required) Comments(Required)Comments(Required) Parent(s)'s InformationMother's Name(Required) First Last Phone(Required)Email(Required) Mailing Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Is the baby's other parent present/involved?(Required) Yes No Father/Other Parent's Name(Required) First Last Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Baby's InformationName(Required) First Last Gender(Required) Female Male Was the Baby Stillborn? No Yes Birth or Stillborn Date(Required) Month Day Year Death Date(Required) Month Day Year Was Baby Full Term?(Required) No Yes If no, Weeks of Gestation:(Required) Funding RequestWe do not need all of the service provider(s) details at this time. The items marked as required are the information we need at this time to be considered for conditional approval. The other information is required for final approval and can be submitted via email within 30 days of conditional approval. Type of Service(Required) Cremation (up to $500) Funeral (up to $1,200) See the Cremation and Funeral Financial Assistance Program details for funding and use limits. Requested Financial Assistance Amount:Will there be a balance due beyond what AFF will be paying? No Yes If yes, how will this balance be paid? Name of Crematorium/Funeral Home: Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneEmail Funeral Director Name: First Last Name of Interment Location: Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneEmail Upload Invoices from Service Providers Drop files here or Select files Max. file size: 256 MB. Financial InformationMUSC Approved Financial Assistance FormMax. file size: 256 MB.Household Income(Required) $0-$35,000 $35,001-$75,000 $75,001-$125,000 Greater Than $125,000 Unknown - I am submitting on behalf of the family (aka not the baby's parent) Household Income is defined as the total income for all members of the family living together. By submitting the form, you attest your answer is accurate given the best of your knowledge. Form SubmissionAcknowledgement(Required) I agree that submitting this form does not guarantee Ari Foss Foundation will approve this funding request and I agree to the below information.The Ari Foss Foundation will review the form submission and follow up with the individual who submitted the form. Invoices are considered part of the Financial Assitance form. The Ari Foss Foundation can give conditional approval without the invoices; however, final approval cannot be given without the invoice(s) from the service providers. The invoice(s) must be submitted within 30 days of conditional approval or the conditional approval will expire. The Ari Foss Foundation directly pays the facility/service providers. Under no circumstances can the Ari Foss Foundation reimburse an individual through the Cremation and Funeral Financial Assistance Program.Signature(Required)NameThis field is for validation purposes and should be left unchanged.
