Financial Aid Application1Instructions2Primary Contact Information3Child's Information4Financial Information5Grant Request6Additional Information7Document Upload8Review How We Can HelpAeron’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 Typical forms of financial aid that may be considered include rent assistance, payment of credit card debt, and gift cards to large vendors (such as Visa, Mastercard, Target, Amazon or major grocery stores). 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. Download Paper ApplicationEligibility 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 2023 Low Income Limits (50%) Summary (Source: https://www.huduser.gov/portal/datasets/il.html)Persons in Family12345678Annual Income Limit$44,150$50,450$56,750$63,050$68,100$73,150$78,200$83,250 ✓ 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 OfficePrimary Contact InformationName* Mr.Mrs.MissMs.Dr. Prefix First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Address* Phone Number*Relation to Child*Preferred Contact Method* Phone Email MailPreferred Language* English Spanish Child's InformationChild's Full Name* First Middle Last Child's Gender* Male Female Ethnicity*American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhiteMultiplePrefer not to answerChild's Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child's Date of Death*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Hospital or Place of Child's BirthCause of Death*LA County Medical Examiner-Coroner Case Number*Financial InformationParent 1Parent 2Name* First Last Name First Last Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ethnicity*American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhiteMultiplePrefer not to answerEthnicityAmerican Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhiteMultiplePrefer not to answerAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhonePhoneEmail Address Email Address Marital StatusSingleMarriedDivorcedWidowedMarital StatusSingleMarriedDivorcedWidowedOccupationOccupationHours of Week at Work*Please enter a number from 0 to 168.Hours of Week at WorkPlease enter a number from 0 to 168.Average Monthly Income*Average Monthly IncomeOther Sources of Monthly Income (examples: social security, alimony, child support, welfare, etc.)*Other Sources of Monthly Income (examples: social security, alimony, child support, welfare, etc.)UntitledCombined Household Monthly Income*Number of Dependents in Family*Relationship to ChildAge Any additional financial information we should be aware of?Grant RequestAmount requested from Aeron's Foundation (Up to $2000)*Please enter a number less than or equal to 2000.Certification of Financial Hardship* I certify that I am in financial hardship and need supportDisbursement Method* Check (i.e. funeral home, cemetery, rent assistance, bills, credit card debt) Gift CardCheck: All checks are sent to the family, but are written directly to the service provider. Please remember that Aeron’s Foundation will not issue checks directly to the family. For rent assistance, please include your lease agreement or a copy of rent bill for verification. If needed, Aeron’s Foundation may contact you to request more information. Gift Card: If you are requesting a gift card, please provide the funeral/cemetery cost information and we will honor the amount up to $2,000. Aeron’s Foundation is unable to re-issue gift cards if they are lost or stolen.Gift Card Organization* Visa Mastercard Target Amazon Ralphs Preferred Gift Card Delivery Method* Hand Delivered Email (If Available)Typically gift cards are hand-delivered to the family, or can be sent through email if this option is available from the vendor.Please write the name of the person or company (service provider) that the check should be issued to.*Service Provider (Who the check will be made out to)Contact Person (if different)Phone Number Recipient Name*Recipient Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Recipient Email* Please describe how this financial assistance will benefit you and your family:*Additional InformationHow did you hear about Aeron's Foundation?*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?* Yes NoWhen in the future would you like to be contacted?* 3 Months 6 Months 12 Months Other Questions or CommentsDocument UploadProof of LA County residency (copy of utility bill, copy of government issued ID, etc.)* Drop files here or Select filesMax. file size: 5 MB. Proof of relationship to child (copy of birth certificate, proof of adoption, etc.)* Drop files here or Select filesMax. file size: 5 MB. Copy of death certificate* Drop files here or Select filesMax. file size: 5 MB. Proof of income (letter from employer, paystub, bank statement, annual tax return, etc.)* Drop files here or Select filesMax. file size: 5 MB. {all_fields}AttestationI 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*I 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*Quotes and Photo Release I authorize Aeron's Foundation to contact me in the future and use any quotes, photos, or other media in promotional and/or marketing materials.Data Retention Agreement* I am aware that all submitted information will be retained a minimum of 7 years.Application Reference IdentifierNameThis field is for validation purposes and should be left unchanged.Δ