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 trainingIII. 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