Aid To Family/Assistance Request Form

Preliminary Request for Assistance Form

Important Note: This preliminary request for assistance form(s) must be received within (6) weeks of a qualifying event to receive consideration. Additional information will be required for your consideration of and receipt of financial benefits.

1. Victim’s Human Resource Department needs to complete the Assistance Request Form Below for the employee’s spouse and beneficiary.

2. HR can submit a Memorial Statement to

3. Questions? Contact Jennifer McCloskey. or 954-817-9590.