Abaseen Foundation

SECTION 1 — APPLICANT

Full Name *

Street Address *

City *

State *

ZIP *

Telephone *

Email *

Relationship to the Deceased *

Describe your relationship with deceased *

SECTION 2 — THE DECEASED

Full Name of Deceased *

Date of Death *

City of Death *

State of Death *

Name of Funeral Home or Mortuary *

Name of Cemetery (if applicable)

City and State Where Funeral/Burial Took/Will Take Place *

SECTION 3 — HOUSEHOLD

Number of People Living in Household *

Total Monthly Income of Everyone in Household (before taxes):

Employment or self-employment
Social Security, disability, or pension
Public benefits or other assistance
All other household income
TOTAL MONTHLY HOUSEHOLD INCOME

Total Savings and Available Funds ($) *

Is any household member receiving public assistance? *

Yes No

SECTION 4 — FINAL EXPENSES

Funeral home / mortuary charges
Cemetery, burial, or interment costs
Transportation of remains (within CA)
Other related expenses (description):
TOTAL FINAL EXPENSES
Less: amounts already paid or covered
UNMET BALANCE

Amount of Assistance Requested (Max $8,000) ($) *

SECTION 5 — OTHER ASSISTANCE

Have you received, applied for, or been promised help from any other source? *

Yes No

If yes, give source and amount:

SECTION 6 — RELATIONSHIP TO FOUNDATION

Are you or anyone in your household a director or officer of Abaseen Foundation? *

Yes No

Are you related to any director or officer of Abaseen Foundation? *

Yes No

If yes to either, give name and relationship:

SECTION 7 — DOCUMENTS ATTACHED

Death Certificate or Funeral Home Statement:

Itemized Statement of Funeral/Burial Charges:

Proof of Household Income:

Photo ID of Applicant:

Proof of California Residence:

SECTION 8 — APPLICANT CERTIFICATION

I certify that the information I have given in this application is true and complete to the best of my knowledge. I understand that assistance is awarded on the basis of need, subject to availability of funds, and submitting this application does not guarantee an award.I certify that the information I have given in this application is true and complete to the best of my knowledge. I understand that assistance is awarded on the basis of need, subject to the availability of funds, and that submitting this application does not guarantee an award. I understand that Abaseen Foundation may pay the funeral home, cemetery, or other provider directly. I agree that any funds provided will be used only for the final expenses described in this application. I understand that Abaseen Foundation may contact the funeral home or cemetery to verify the amounts stated.

Print Name *

Date *

Digital Signature (Full Legal Name) *