Request for the Survivor Fund

Click here to download the Information Packet.

General Information
Date of Submission*
MM slash DD slash YYYY
Would you like to request inclusion on The Wall of the Fallen as well?*
- Yes
- No
Name of Deceased*
Gender
Date of Birth*
MM slash DD slash YYYY
Date of Death*
MM slash DD slash YYYY
Legal Name of the Deceased's Spouse
Name (s) of the Deceased's Children (if applicable)
Company Information
Name of Company the Deceased Worked For*
Company Address*
Street Address Address Line 2 City State / Province ZIP / Postal Code Country
Company Phone*
Company Fax
Company Email*
Years in Towing Industry*
Position of the Deceased With the Company*
Is the Company or Individual a Towing Museum Member?*
- Yes
- No
Submitter Information
Name*
First Last
Relationship to the Deceased*
Address*
Street Address Address Line 2 City State / Province ZIP / Postal Code Country
Phone*
Fax
Email*
Fund Distribution Information
Distribution should be made to closest living relative 18 or older
Name of Person Requesting Funds*
Relationship to the Deceased*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Fax
Email*
Incident Information
Date of Incident*
MM slash DD slash YYYY
Time of Incident
Location*
City State / Province / Region
Road Type*
Time of Incident*
Incident Details*
Documents
Next of Kin Affidavit required for submission. Additional Documents are not required in order to qualify
Next of Kin Affidavit (Required to dispense funds)*
Please have the next of Kin fill out this form then upload for submission: Click here to download. (PDF file will open in a new window)
Max. file size: 512 MB.
Death Certificate
Max. file size: 512 MB.
State Association Information
Max. file size: 512 MB.
Copy of Marriage Certificate
Max. file size: 512 MB.
Obituary
Max. file size: 512 MB.
Birth Certificates for Dependent Children
Max. file size: 512 MB.
Police Report of Incident
Max. file size: 512 MB.
Newspaper Article(s)
Max. file size: 512 MB.
Other
Max. file size: 512 MB.
Name of Police Department
Phone of Police Department
All pertinent documents should be attached to this form for submission. A copy of the police report should be submitted with this request if available. I certify that the above information is true and correct to the best of my knowledge at the time of submission. I understand that review by ITRHFM is confidential, and that its decision is final. I also understand that any award is discretionary, and that meeting the eligibility criteria does not guarantee an award. Should an award be made to me, I agree in advance to allow ITRHFM to list and publish the donation to me and my family.
Signature of the Submitter*
Date*
MM slash DD slash YYYY
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Comments
This field is for validation purposes and should be left unchanged.

Privacy Information: Submitting information is strictly voluntary. By doing so, you are giving the ITRHFM your permission to use the information for the intended purpose. If you do not want to give the ITRHFM Permission to use your information, simply do not provide it. However, not providing certain information may result in the ITRHFM ‘s inability to provide you with the services you desire.
© 2023 International Towing and Recovery Hall of Fame and Museum

General Information

Company Information

Submitter Information

Fund Distribution Information

Incident Information

Documents