Name
Date
Email
Phone
Address
City
State
Zip
Are you living with MS?
Are you living with MS?
Yes
No
What year were you diagnosed?
Who is your MS Doctor?
Are you a single parent?
Are you a single parent?
Yes
No
How many children do you have and ages?
If yes to the above, please answer the following:
Financial
What is your work status?
What is your work status?
Retired
Full Time
Part Time
Disability
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
Medical equipment
Medical needs
Household renovations
Transportation assistance
Future Academic support
Other (non financial)
Have you ever received assistance from us before, if yes, when and amount
Are you receiving any assistance from other programs?
Are you receiving any assistance from other programs?
Yes
No
Community Resources Contacted
Please list the name and phone numbers of the contacts of these organizations
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?
Can documentation for income/expenses be provided?
Yes
No
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
You must be able to provide either a tax return or a lease that verifies you are a single parent and the primary caregiver
Please provide a copy of your lease or tax return
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.
Date
Printed Name
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