Shareholder Bereavement Assistance Request

Far West, Inc. Section 7(r) Bereavement Policy provides Shareholder's Bereavement Assistance of up to $1,000.00 on behalf of a FWI shareholder, or $500.00 on behalf of a lineal descendant of a FWI shareholder, to help defray the cost of funeral expenses for the deceased FWI shareholder or lineal descendant. “Lineal descendant” means a child or grandchild of a FWI 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:

Please enter the name of the deceased.

Date of Death:

Please enter the date of death.

Date of Birth:

Please enter the date of birth.

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

Please choose one option.

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

Please choose one option.

Upload Supporting Document

Please attach a supporting document (PDF or Word, 2 MB max).

PDF or Word document, 2 MB maximum.

Payable to:

Please enter who payment should be made out to.

Mailing Address:

Please enter a mailing address.

Phone (including area code):

Please enter a 10-digit phone number, including area code.

Email address:

Please enter a valid email address.

Payable for:

Please enter what the payment is for.

CERTIFICATION:

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

Signature:

Please sign in the box above.

Date:

Please enter the date you signed.

Relationship to Deceased:

Please enter your relationship to the deceased.

Full Name:

Please enter your full name.

SSN:

Please enter a 9-digit Social Security number.

Address:

Please enter your address.

Phone:

Please enter a 10-digit phone number, including area code.

Cell phone:

Please enter a 10-digit cell phone number, including area code.