SJ4H Financial Assistance Application

SJ4H Financial Assistance Application

A Program of Lost&Found
Application Overview

Lost & Found’s Survivors Joining for Hope (SJ4H) program provides financial assistance and resource support to individuals and families experiencing financial hardship due to a recent loss by suicide. Applications should be filled out by the primary family member or loved one handling financial responsibilities. One application per family.
Lost&Found will consider all applications regardless of applicant's race, gender, age, religion, sexual orientation, and economic status.

Guidelines for financial assistance:
- Financial support will be provided to approved applicants no more than one year following the loss of a family member or loved one by suicide.
- All approved funds must be paid directly to a company or organization providing support to the impacted individual/family seeking support.
- Applicants must reside in SD, MN, IA with preference given to SD residents.
- Qualifying expenses include funeral expenses, burial expenses, grief counseling, legal fees, or expenses deemed necessary by Lost&Found Advisory Committee.
- Either the applicant, funeral home, or local coroner must verify cause of death prior to the distribution of funds.
Lost&Found's mission is to provide comprehensive suicide prevention and postvention services for youth and young adults (ages 10-34) and their support networks. Preference will be given to applications to support these groups where possible.

Assistance amounts are determined on a case-by-case basis by the SJ4H Advisory Committee for approval and assistance amounts (within service area/majority, beyond service area/unanimous). Maximum assistance is $2,500 per family unless circumstances dictate otherwise. Lost&Found considers income levels relative to area median gross income (AMGI), as well as financial stressors, to maximize the impact of the SJ4H Financial Assistance Program.
Applicant Information

Person Completing the Form
Name*

First NameLast Name
Relation to Deceased*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you worried about losing your housing?*

YesNoOther
Do you feel physically and emotionally safe where you currently live?*

YesNoUnsure
Race*

White / CaucasianBlack or African AmericanHispanic or LatinxAsian or Asian AmericanAmerican Indian or Alaska NativeNative Hawaiian or other Pacific IslanderOther
Tribal Enrollment (if applicable)
Gender*
How did you hear about us?*
Loved One's Information
Name*

First NameLast Name
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*
Race*

White / CaucasianBlack or African AmericanHispanic or LatinxAsian or Asian AmericanAmerican Indian or Alaska NativeNative Hawaiian or other Pacific IslanderOther
Tribal Enrollment (if applicable)
Name of College or University attended at time of death (if applicable)
College Name, City, State
Name of workplace at time of death (if applicable)
Business Name, City, State
Was your loved one a Veteran of the armed forces?*

YesNo
Assistance Request

Please note that assistance will only be provided for fees/services with an outstanding invoice as the payment is made directly to service providers. Payments are not made directly to applicants or their families.
Type of Assistance Needed*

Funeral AssistanceBurial FeesGrief CounselingLegal AssistanceOther Financial Needs
Amount Requested for Assistance*
Please list the total amount of outstanding bills
Finanical Information
Please verify that you are the person taking on financial responsibility for expenses related to the death of your loved one.*

Yes, I am taking on sole responsibility for expensesYes, and I have help from other family members or friendsNo, I am not the primary person handling expense
What is your current work situation?*

UnemployedPart-time or temporary workFull-timeUnemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)
What is your main insurance?*

None/uninsuredMedicaidMedicareCHIPOther Public InsurancePrivate Insurance
Household Size*
Include yourself and the number of people you claim on your taxes.
Please provide the following information about each of your household members: Name, Age, Gender.*
Annual Household Income (Total Gross Income)*

Less than $10,000$10,000 to $19,999$20,000 to $29,999$30,000 to $39,999$40,000 to $49,999$50,000 to $59,999$60,000 to $69,999$70,000 to $79,999$80,000 to $89,999$90,000 or more
Do you have any additional financial concerns at this time? Please list*
Ex. - other outstanding bill amounts, major job or income changes, struggling to make ends meet, unable to afford acess to supportive services like counseling etc.
Are you or any family members you live with concerned about meeting any of the following needs? Check all that apply.*

FoodClothingUtilitiesChild CareEmploymentMedicine or Health CarePhone AccessTransportationOtherNo Other Concerns At This Time
Funeral Arrangements
Funeral Home*
Contact Person & Phone Number*
Cemetery*
Does the deceased have a plot?*

YesNo
Cremation or Burial?*
Date of Services*

MonthDayYear
Date
Next Steps: Our program coordinator will be giving you a call to discuss your application within 1-2 business days. We look forward to talking with you soon, we are truly sorry for your loss.
Should be Empty:

SJ4H Financial Assistance Application

Application Overview

Applicant Information

Loved One's Information

Assistance Request

Finanical Information

Funeral Arrangements