FUNERAL ASSISTANCE FORM

"*" indicates required fields

Your Name*

First Last

Your Email*

Phone*

Your Relationship to the Deceased*

Name of the Deceased*

First Last

Date of Birth of the Deceased*

MM slash DD slash YYYY

Date of Death*

MM slash DD slash YYYY

Place of Birth*

Circumstances of Death*

Address of the Deceased*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Survivors of the Deceased (Check ALL that apply)*

Spouse

Mother/Father

Brother(s)/Sister(s)

Child/Children Under Age 18

Child/Children Over Age 18

None

Email of Local Relative*

What was the annual household income of the deceased?*

Was the deceased the primary earner in the household?*

Benefits received by the family (Check ALL that apply)*

Medicaid

Housing Voucher

SSI

TANF

SNAP

None

How much can the surviving loved ones contribute to the funeral expense?*

In order for Dar Al-Hijrah to be able to assist in funding, the surviving loved ones must be able to contribute a minimum of $2,500.

Is there any other information you can share to help us better understand the situation?

Would you like to make a continuous charity on behalf of the deceased?

Yes

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