Apply for Funding.

We only provide financial assistance to help pay outstanding funeral, cemetery and medical expenses or counseling (up to 3 sessions).

After applying & receiving email confirmation, you may be required to provide a copy of the bill if we are not able to retrieve one on your behalf.
We pay the business directly that is issuing the bill.
We do not offer assistance outside of Nebraska.
We only approve funding after a passing has occurred.
We only fund medical expenses that result directly from a loss.
For medical expenses, it is recommended to apply after the bill has been received and insurance has gone through.

Contact Name

Person who is filling out the application.

First Name

Last Name

Contact Email

Email of person filling out the application.

Mother's Name

First Name

Last Name

Mother's Phone or Email

If same as contact email, put "same".

Father's Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of Loss

Type of Funding

Insurance

If you are requesting assistance for a medical bill, has it already been ran through your insurance?

Date of Birth of person who is listed on the bill.

YYYY

Please list the business issuing the bill(s).

Any Additional Information

If this is a medical bill, please include the account/guarantor #

Total Balance

How did you hear about us?