SIDS America

SIDS America Financial Aid Application

In accordance with IRS guidelines for providing emergency hardship aid to individuals, SIDS America provides short-term assistance to individuals and families suffering an emergency hardship due to the sudden loss of a child to SIDS. Such aid is intended to assist families from suffering additional trauma due to unexpected cost related to their loss.

If your child has died of Sudden Infant Death Syndrome (SIDS) and you are in need of financial assistance for medical, funeral, burial, or grave marker costs relating to the child's death and/or you are in need of grief counseling for you or your immediate family, please fill out the application below in as much detail as possible. Having a family member, friend, etc. fill it out for you is ok as well. Once we receive the application, we will review it, then contact you to discuss the next step.

SIDS America reviews each application individually and determines the amount of aid that SIDS America is able to provide based on the individual/family need and funding available. Criteria used to determine aid to be provided include: (a) the type and amount of unexpected costs facing the family due to the loss of their child; (b) the financial hardship such unexpected costs will place on the family; and (c) the financial need for the aid and other resources available to the family to assist meet this need.

It's our desire to lift the heavy financial burden that we know you might be experiencing due to the death of your child. We want you to know that you are not alone, we appreciate you reaching out to us, and we truly want to serve you and your family.

Applicant Information

Father's Name (First, Last): *

Mother's Name (First, Last): *

Address: *

City: *

State: *

Zip: *

Father's Phone/Cell: *

Mother's Phone/Cell: *

Father's Email: *

Mother's Email: *

Who is filling out this application?: *

If you are a friend, family member, etc. filling this application out on behalf of the parents of the child, please provide your name (First, Last), phone number, email, and your relationship to the child and/or parents (i.e. - grandparent, aunt, uncle, sister, brother, friend, co-worker, social worker, etc.). If you are the father or mother, simply type your name (First, Last).

Child Information

Name Of Child (First, Middle, Last): *

Nickname, if applicable:

Date of Birth: *

Name of hospital, birthing center, etc. where your baby was born: *

Please also provide the city/state

Date of Death: *

Did your child have a life insurance policy?: *

Did your child have health insurance?: *

Name of Funeral Home: *

Please also provide a contact name, phone number, and city/state.

Name of Coroner's / Medical Examiner's Office: *

Please provide a contact name and phone number.

Attachments:

If you need to upload a death certificate, you may do so here.

Name of Police Chaplain:

Please provide contact name and phone number.

Do you have other children? If so, please provide name(s) and ages(s).:

Additional Information

Describe Financial Assistance Needed:

Please describe the expenses for which financial assistance is needed, such as funeral, burial, grave marker, or emergency medical costs associated with your child's death, or grief counseling for you or your immediate family.

Describe Your Specific Financial Hardship Caused by Your Child's Unexpected Death:

Please describe how the unexpected loss of your child and the related financial expenses will cause you and your family additional hardship, such as inability to pay normal costs of housing, food, and transportation, depletion of all savings, loss of automobile, loss of job, etc.

Have you requested and/or received financial assistance from family, friends, coworkers, businesses, churches, or any other individual and/or organization? If so, from whom and how much?:

Have any fundraising activities been conducted by you or on your behalf to help with your financial need?:

If so, please describe what has been done and how much has been raised.

Are you, your spouse, or both currently employed?:

If so, please provide the company name(s) and contact name(s), phone number(s) and email(s).

Have you reached out to, or been contacted by any other nonprofit organizations or foundations?:

If so, please list them here.

Have you attended or been referred to any support groups?:

If so, please provide the name, phone number, and/or email of the group leader. If not, would you like more information about faith-based SIDS support groups in your area?

Have you visited with or been referred to a grief support counselor?:

If so, please provide a contact name and phone number. If not, would you like more information on a grief counselor in your area?

Do you have a religious and/or denominational preference?:

If so, please provide your religious or denominational preference.

Do you attend a church?:

If so, please provide the name including city/state.

Can you briefly explain the events, environment, discovery, and details surrounding your baby's death? :

Additional Comments and/or Information:

Please feel free to include any additional comments and/or information above that you feel would help us better serve you.

SIDS America

SIDS America Financial Aid Application

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