Financial Assistance Application 1Instructions2Primary Contact Information3Child’s Information4Financial Information5Grant Request6Additional Information7Document Upload8Review InstagramThis field is for validation purposes and should be left unchanged.How We Can Help Aeron’s Foundation provides financial assistance for expenses that bereaved parents face in making final arrangements for their baby who has died. This is made possible due to the generosity of private donations and fundraising efforts. If you are a bereaved parent or family member seeking assistance with funeral costs, or if you are experiencing financial hardship due to these expenses, please complete the following application. Starred fields must be filled out. Submitted applications will be reviewed and response will typically be provided within 4 weeks of submission. Please remember to include supplemental documentation, and send us an e-mail in order to ensure prompt processing of your application. If submitting through postal mail, please send the application to: Aeron’s Foundation Attention: Financial Assistance P.O. Box 56061 Sherman Oaks, CA 91413 Financial aid will be granted in the form of Visa gift cards. Aeron’s Foundation cannot issue checks directly to the family. Families are eligible to receive financial aid up to one year after the loss of your child. For more information please contact info@aeronsfoundation.org. Before You Start We recommend that you download a copy of the application form prior to beginning your online submission to ensure you have all the required information and documents. Paper Application – English Paper Application – Spanish Eligibility requirements ✓ Low income household as defined by the Department of Housing and Urban Development (income does not exceed 50% of median income in Los Angeles County): Los Angeles County FY 2025 Low Income Limits (50%) Summary – Effective April 01, 2025Source: https://www.huduser.gov/portal/datasets/il.html Persons in Family 1 2 3 4 5 6 7 8 Annual Income Limit $53,000 $60,600 $68,150 $75,750 $81,800 $87,850 $93,900 $100,000 ✓ Child must be 12 months or younger, with undetermined cause of death. ✓ Must be a resident of Los Angeles County. ✓ Case must have been submitted to the LA Medical Examiner’s Office Primary Contact InformationName(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Address(Required) Street Address Address Line 2 City ZIP Code Email(Required) Phone(Required)Relation to Child(Required)Preferred Contact Method(Required) Phone Email Mail Preferred Language(Required) English Spanish Other Child's InformationChild's Full Name(Required) First Middle Last Child's Gender(Required) Male Female Other Child's Ethnicity(Required)American Indian / Alaska NativeBlack or African AmericanNative Hawaiian / Pacific IslanderAsianHispanic or LatinoWhiteMixedPrefer not to answerChild's Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's Date of Death(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Hospital or Place of Child's BirthCause of Death(Required)LA County Medical Examiner-Coroner Case Number(Required) Financial InformationParent 1Parent 2Name(Required) First Last Name First Last Date of Birth Month Day Year Date of Birth Month Day Year EthnicityAmerican Indian / Alaska NativeBlack or African AmericanNative Hawaiian / Pacific IslanderAsianHispanic or LatinoWhiteMixedPrefer not to answerEthnicityAmerican Indian / Alaska NativeBlack or African AmericanNative Hawaiian / Pacific IslanderAsianHispanic or LatinoWhiteMixedPrefer not to answerAddress(Required) Street Address Address Line 2 City ZIP Code Address Street Address Address Line 2 City ZIP Code PhonePhoneEmail Email Marital StatusSingleMarriedDivorcedWidowedSeparatedDomestic PartnershipMarital StatusSingleMarriedDivorcedWidowedSeparatedDomestic PartnershipOccupationOccupationHours of Work per Week(Required)Please enter a number less than or equal to 168.Hours of Work per WeekPlease enter a number less than or equal to 168.Average Monthly Income(Required)Examples: monthly paystub, letter from employer, etc.Average Monthly IncomeExamples: monthly paystub, letter from employer, etc.Other Sources of Monthly Income(Required)Examples: social security, alimony, child support, welfare, etc.Other Sources of Monthly IncomeExamples: social security, alimony, child support, welfare, etc.Combined Household Monthly Income(Required)Number of Dependents in Family(Required)Relationship to ChildAge Add RemoveAny other financial information we should know about? Grant RequestAmount requested from Aeron's Foundation (up to $2000)(Required)Please enter a number less than or equal to 2000.Gift Card(Required) Visa Mastercard Target Amazon Ralphs Other Aeron’s Foundation is unable to re-issue gift cards if they are lost or stolen.Recipient Name(Required) First Last Recipient Address(Required) Street Address Address Line 2 City ZIP Code Recipient Email(Required) Please describe how this financial assistance will benefit you and your family:(Required) Additional InformationHow did you hear about Aeron's Foundation?(Required)A certain number of SIDS cases have been attributed to underlying conditions that may not be apparent upon autopsy (such as heart rhythm issues, seizures, etc). Such conditions may be detected through genetic testing and if found may be useful in screening other family members (such as siblings) for their risk of sharing the same condition. Would you like to be contacted for further information about genetic testing for your child?(Required) Yes No When in the future would you like to be contacted?(Required) 3 Months 6 Months 12 Months Other Other Questions or Comments: Document UploadProof of LA County Residency(Required) Drop files here or Select files Max. file size: 5 MB, Max. files: 3. Copy of utility bill, copy of government issued ID, etc.Proof of Relationship to Child(Required) Drop files here or Select files Max. file size: 5 MB, Max. files: 3. Copy of birth certificate, proof of adoption, etc.Proof of Income(Required) Drop files here or Select files Max. file size: 5 MB, Max. files: 3. Letter from employer, paystub, bank statement, annual tax return, etc. {all_fields}Signature AttestationI hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may disqualify me for financial assistance(Required) I agreeI hereby acknowledge that Aeron's Foundation reserves the right to verify the information contained in my application at any time including but not limited to financial information, employment, quotes, and LA County Medical Examiner-Coroner's office case information(Required) I agreeI am aware that all submitted information will be retained a minimum of 7 years.(Required) I agreeFull Name(Required)Application Reference Identifier Δ
