Financial Assistance – Madison's Miracles

Donations made are used to help cover funeral costs, and counseling services for grieving family members. If you are in need of financial assistance and reside in Martin or St. Lucie County, you may use the form below to submit your request.

Application for Financial Assistance

Mother's Name*
First Last
Father's Name*
First Last
Child's Name*
First Last
Date of birth
MM slash DD slash YYYY
Date of death
MM slash DD slash YYYY
Gender*
Gestation*
Reason for Demise*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
County*
Upload proof of residency. (Power, water or Utility bill)
Max. file size: 64 MB.
Phone*
Email*
Services Requested
Hospital*
Funeral Home*
Contact*
Phone*
Annual Household Income*
Requested Grant Amount*
Have you ever received help from Madison’s Miracles?*
What help did you receive?*
Please enter date of help received*
MM slash DD slash YYYY
Do you have insurance?*
What is your copay for Counseling Services?*