Funeral Grant Application – Michael R. Walker Foundation

MRWF - Funeral Grant Application

Please Note - In order to be considered for assistance, the employee must be legally responsible for the unexpected funeral expenses.

Step 1 of 2

Employee Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Employee ID(Required)

Home Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

County of Residence(Required)

Center/Site Location(Required)

Please select Division/Market that applies to you(Required)

Job Title(Required)

Hire Date(Required)

Shift/Time usually at work(Required)

Employment Status(Required)

Hours Per Week(Required)

Who is filing out the form?(Required)

if not applicant, please supply name and title or relationship to employee

Date(s) of Hardship(Required)

Please describe hardship/situation details and how the situation is the employee's financial responsibility.(Required)

Information about the deceased

Deceased Name(Required)

Date of Death(Required)

Relationship of the deceased to the employee(Required)

Did the deceased reside with the employee at the time of passing?(Required)

Are you Legally responsible for the funeral costs?(Required)

If so, please describe?

Location of Funeral (State, Country, etc.)(Required)

Funeral Home Name, Contact and Telephone(Required)

Funeral Home Bill total(Required)

Please Provide a Copy of the Funeral Bill

Max. file size: 768 MB.

If you are unable to upload, please fax to 610-347-6217 or email to mrwfoundation@genesishcc.com.

Please Provide a Copy of the Obituary

Max. file size: 768 MB.

If you are unable to upload, please fax to 610-347-6217 or email to mrwfoundation@genesishcc.com

Was the deceased cover under Life Insurance?(Required)

What is the amount of the Life Insurance?(Required)

Are there other funeral benefits such as Medicaid, VA, other? If so, please explain(Required)

If needed, have you contacted EAP - Health Advocates for resources?(Required)

Travel or other needs? If so, please explain and total need(Required)

If you are requesting assistance with travel, please upload paid travel itinerary, receipts, death certificate, obituary, etc.

Max. file size: 768 MB.

If you are unable to upload, please fax to 610-347-6217 or email to mrwfoundation@genesishcc.org

Funds

Requested Amount(Required)

How will grant funds be used?(Required)

If a grant is approved, will you allow MRWF to share your story?(Required)

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Grant Coordinator

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Grant Notes:

Giving, Helping, Caring

MRWF - Funeral Grant Application

Employee Information

Information about the deceased

Funds