Application for Assistance

Aubrielle’s Hope provides assistance for New Hampshire families with funeral, burial and/or cremations for children five years old and under within 30 days of a loss. These funds are for upfront costs and cannot be used for reimbursements. In order to apply for assistance, the custodial parent of such child must submit this completed form to our Board of Directors for review, A representative from Aubrielle’s Hope will then contact the family directly with our offer of support. The only thing we ask for in response of assistance is a short statement from the family acknowledging our help. These items will be posted on our website and may be used by Aubrielle’s Hope to communicate how we are helping New Hampshire families facing the loss of a baby; fostering continued support for our mission.
Email address *
How did you hear about Aubrielle’s Hope?
Your answer
Name of Child: *
Your answer
Age *
Your answer
Date of birth-Date of Death *
Your answer
Cause of Death *
Your answer
Custodial Parent(s) Full Name *
Your answer
Legal Address *
Your answer
Mailing Address (if different) *
Your answer
Home Phone Number
Your answer
Cell Phone *
Your answer
Email *
Your answer
Average Household Income *
Your answer
Any additional information that Aubrielle’s Hope might find relevant (loss of job, no family resources, etc): *
Your answer
Any other children living in the home and their ages:
Your answer
Please provide the contact information of the Funeral Home or Cemetery that you are asking for help with payment to. Attach the release of information sheet to show that the Funeral Home or Cemetery has permission to verify the information contained in this application. (Applications cannot be processed without verification by the director of the Funeral Home or Cemetery.)
Name of Funeral Home or Cemetery *
Your answer
Name & Title of Contact Person *
Your answer
Address *
Your answer
Telephone *
Your answer
Email *
Your answer
Please describe specifically what the money will be used for (must be a part of funeral, burial, cremation and/or associated fees): *
Your answer
How much is the cost to you for the funeral, burial and/or cremation? *
Your answer
We require the following additional information/ documentation to be attached to application:
• Copy of signed Release of Information Form from Funeral Home or Cemetery
*Email a scanned copy to: Aubrielleshope@yahoo.com

Aubrielle’s Hope’s assistance will be provided at the discretion of the Board of Directors and may only include assistance for the burial, cremation or funeral of a child who passes away five years old and younger in New Hampshire. The board reserves the right to approve a portion of funds requested. Funds will be dispersed to businesses directly providing services. If your application is accepted, your response is required within 48 hours or funds will be re-allocated. Approval is contingent upon complete and verifiable applications and available funds. We do not discriminate based on religion, race and sexual orientation.

A copy of your responses will be emailed to the address you provided.
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