Form 1

Maurice de Madre French Fund (FFMM)

Application form

For the payment of benefits tothe family of a person deceasedwhile working for one of the components

of the International Red Cross and Red Crescent Movement

I. National Societymaking the request:

......

Person handling the matter at the National Society's headquarters (name, title):

......

II. Details of the deceased

-Surname:......

-First/other names:......

-Date of birth:......

-Place of birth:......

-Address:......

-Marital status (single, married, divorced, widowed):......

-Dependents:

Relationship to the deceased / Surname / First/other names / Date of birth / Activity

-What expenses of the beneficiaries were covered by the deceased?

......

For any beneficiaries who are minors, attending school, studying or in training:

Surname and first/other names / Educational establishment / Number of years completed / Years remaining / Cost (per term or year) of school, studies or training

III. Work outside the RC/RC Movement

-Profession:......

-Date last salary received:......

-Are the intended beneficiaries of support from the FFMM also beneficiaries of insurance cover taken outby the employer? YES NO (delete whichever does not apply)

Amounts received/to be received:......

IV. Activities within the National Society, the ICRC or the Federation

Duties / From when to when? / As paid staff? / As a volunteer?

-What was the deceased’s most recent salary?......

-Date on which last salary, allowancesor expenses payment was received:......

-Are the intended beneficiaries of support from the FFMM also beneficiaries of insurance cover taken outby the NS, the ICRC or the Federation (not the FFMM): YES NO (delete whichever does not apply)

Amounts received/to be received:......

V. Circumstances of death

Date, place, brief description of the facts (please attach a death certificate)

Please return this form to:

Secrétariat du FFMM, c/o CICR, 19 avenue de la Paix - 1202 Genève - Suisse