Apply for Funding.

We only provide financial assistance to help pay outstanding funeral, cemetery and medical expenses (after insurance) that pertain to the loss.

After 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 billing company directly.
We do not offer assistance outside of Nebraska.
We only approve funding after a passing has occurred.
It is recommended to apply after the bill has been issued.

Contact Name

Person who is applying

First Name

Last Name

Phone (Optional)

(###)

###

####

Contact Email

Mother's Name

First Name

Last Name

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 #

Balance on bill (if known).

How did you hear about us?