Shareholder Bereavement Assistance Request

Far West, Inc. Section 7(r) Bereavement Policy provides Shareholder's Bereavement Assistance of up to $500 to help defray the cost of funeral expenses for FWI Shareholders of Settlement Common Stock (hereafter, "FWI Shareholder") as a result of the death of a shareholder. Payment is subject to the following:

This form must be signed by next of kin family representative or court appointed personal representative.
Payment will be made directly to funeral home or other approved vendor (please attach invoice if available).
The deadline for filing for bereavement assistance is within thirty (30) days of date of death.

Name of Deceased:

Date of Death:

Date of Birth:

Deceased is:
An FWI Shareholder who is Native
Lineal descendent of an original FWI Shareholder who is Native

Applicant must include one of the following which includes name and date of death:
Death Certificate
Published Obituary (not a program used at service)
Letter from Funeral Home
Letter from Hospital

Upload Supporting Document

Payable to:

Mailing Address:

Phone (including area code):

Email or fax:

Payable for:

CERTIFICATION:

By my signature below, I certify that the funds received are to help pay for funeral related expenses.

Signature:

Date:

Relationship to Deceased:

Full Name:

SSN:

Address:

Phone:

Cell phone: