Loss Assistance - The Colette Louise Tisdahl Foundation

Expenses Post Loss

Are you in the right place?

This application should be submitted in these cases:

Pregnancy loss.
Miscarriage.
Stillbirth.
Neonatal death.
Infant death up to one year of age.
If you have another loss, please contact us. before filling out the application.

If you have questions, please contact us.

Important: Must Read

All applications require a verification from a third party. An application will only be reviewed with a verification.

Please click here to find out more about what constitutes a verification.

We require information on income in a number format (this can be a range if needed). The use of N/A, unknown, or nothing, and other similar terms will not be accepted and your application will be closed.

Loss Application for Support

"*" indicates required fields

Name of Person Requesting Financial Assistance*

Please put parent or guardian's name, not child's name

First Last

Name of Person Filling Out Application (if different than above)

First Last

Who is Filling Out This Form?*

Parent

Social Worker/Case Manager

Other

If you selected other above, please explain who you are

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*

Gestational age at 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 you plan to cover with these funds (please be as detailed as possible)*

Upload any applicable files

Max. file size: 50 MB.

Anything else you would like us to know in order to make our decision?