SECTION 1: APPLICANT INFORMATION

Full Name:

Relationship to Organ Donor:

Address:

City: State: Zip:

Phone Number: Email Address:

Preferred Method of Contact: PhoneEmail

SECTION 2: DONOR INFORMATION

Name of Organ Donor:

Date of Passing:

Hospital / Location of Donation:

Was your loved one a registered organ donor? YesNoUnsure

SECTION 3: HOUSEHOLD FINANCIAL INFORMATION (CONFIDENTIAL)

Estimated Annual Household Income (before taxes):
Under $25,000$25,000 – $50,000$50,000 – $75,000$75,000 – $100,000Over $100,000

Has your household experienced loss of income due to your loved one’s passing? YesNo

Income Verification (Provide ONE if available):
Most recent federal tax return (first page only)Two recent pay stubsUnemployment or disability benefit statementSocial Security benefit statementWritten explanation if documentation is unavailable

This information is confidential and used solely to determine eligibility.

SECTION 4: TYPE OF ASSISTANCE REQUESTED

Funeral / Memorial ExpensesTravel & LodgingGrief CounselingTemporary Living Expenses (Rent, Utilities, etc.)Medical Bills Related to Final CareEmergency Financial AssistanceOtherIf Other:

Amount Requested (if known): $

SECTION 5: FINANCIAL HARDSHIP STATEMENT

Please describe your current financial hardship and how this assistance would support your family:

SECTION 6: REQUIRED DOCUMENTATION

Government-Issued Photo IDProof of Relationship to DonorCopy of Death CertificateRelevant Bills / Invoices Related to Request

SECTION 7: CERTIFICATION & CONSENT

I certify that the information provided in this application is true and accurate to the best of my knowledge.
I understand submission does not guarantee assistance.

Other Documents - Please upload any supporting documents:

The Foundation reserves the right to request additional documentation to verify eligibility.

Signature (Just type your full name as an eSignature)

Date:

The Justin Beltran Memorial Foundation is a 501(c)(3) nonprofit organization. Assistance is provided based on documented need and available funds.

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