Family Application

If your family or one you know is struggling with MS as a single parent, please complete the following form and submit it to us for assistance.

Name

Date

Phone

Address

City

State

Zip

Are you living with MS?

Are you a single parent?

How many children do you have and ages?

If yes to the above, please answer the following:

Financial

What is your work status?

Total Monthly Income (work, disability, alimony, etc.)

Monthly Mortgage/Rent

Utility Expenses

Credit Card Debt

Other Major Expenses

Total Monthly Expenses

Assistance/Support Request

Type of Assistance needed

Have you ever received assistance from us before, if yes, when and amount

Are you receiving any assistance from other programs?

Community Resources Contacted

Please list any community resources or organizations the applicant has contacted for support or assistance (housing, food banks, disability services)

Verification and Documentation

Can documentation for income/expenses be provided?

If direct payment to vendor, please be aware that we will need a w-9 from them and or you if over $600.00

Please explain why we should choose you.

Please provide a copy of your drivers license, passport or State ID

Please provide a copy of your drivers license, passport or State ID

Please provide the 1st & 2nd page of your W-2 form with your SS number

Please provide the 1st & 2nd page of your W-2 form with your SS number

**PLEASE NOTE YOU MUST INCLUDE A LETTER FROM YOUR DOCTOR STATING YOU ARE BEING TREATED FOR MULTIPLE SCLEROSIS

PLEASE NOTE YOU MUST INCLUDE A LETTER FROM YOUR DOCTOR STATING YOU ARE BEING TREATED FOR MULTIPLE SCLEROSIS

I certify that the information I have provided on this form is true, complete, and accurate to the best of my knowledge. I understand that providing false or misleading information may affect my eligibility for services and may result in other consequences as permitted by law. By signing below, I agree to the above certification. My signature may be provided either in writing or electronically.

Signature

Date

Printed Name

"I don’t even have the words to express how generous the gifts for the children and my self are! I spent so much of the day crying but it was also happy tears!!"