Expenses Post Loss

This form should be used in cases of loss such as:

Miscarriage

Etopic pregnancy

Other pregnancy loss

Stillbirth

Infant loss

Acceptable verification has to fall under one of the following categories:

A healthcare provider verification form submitted online on our website at www.colettelouise.com that is appropriately filled out by the third party with complete name, title, and contact information.
A healthcare provider writing a letter on the appropriate letterhead and emailing said letter directly to us at michelle@colettelouise.com. The email must come from whoever wrote the letter and it must be from their official work email and include their full name and contact information in either the letter or the email.
In cases of loss, documentation submitted or sent from either healthcare provider or parent applying that is official government or hospital paperwork. This may include a death certificate, the official paperwork that hospital completes for a death, or a detailed medical write up (not discharge paperwork) that shows the logo and contact information for the hospital or doctor as well as contact information for follow up.

For personal, family reasons, we will not be reviewing applications at this time. We will still accept applications and verifications and hope to review starting the weekend of October 6.

Without the proper verification, we cannot process your application. We also reserve the right to follow up with those writing verifications for more information or to verify the validity of the verification. If we find after verifying that the information is not accurate, your application will be denied. If you have questions as to what is acceptable or have a different verification other than one listed, please do not hesitate to reach out and we can try to come up with a solution.

NOTE--IF INCOME INFORMATION IS NOT ENTERED AS A NUMBER (RANGE IS FINE) OR IF THE NUMBER OF PEOPLE IN A HOUSEHOLD IS NOT ENTERED, THE APPLICATION WILL BE IMMEDIATELY CLOSED.

"*" indicates required fields

Name*

First Last

Email*

Address*

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

Phone*

Child's Name*

Baby's Date of Birth*

Baby's Date of Death*

Number of People Living in the Household*

Total Household Income from Most Recent Tax Return*

Expected Total Household Income for Current Calendar Year (from all sources)*

If you have additional information that may help us make a determination regarding your application, such as large outstanding bills which would show financial hardship, please list those circumstances here (example: phone bills, electricity bills, medical bills, bank or checking statements, etc.)

How Much Are You Requesting from The Colette Louise Tisdahl Foundation?*

Expenses that you will use money for with details*

Upload any applicable files

Max. file size: 50 MB.