Grant Request Form

ALS United North Carolina Care Grant - Request for Funds Form

Commplete this form to submit a Request for Funds and upload your receipts (at the bottom of the page) that match the amount you are requesting. Receipts must be clear and include all information required according to the Instructions for Applying on the main Care Grant page. You may submit Request for Funds with eligible receipts up to 3 times/period, for a maximum of $750.

Person with ALS(Required)
Mailing Address(Required)
If mailing address is a PO Box, you must provide a physical address below
Physical Address (must be provided if mailing addres is a PO Box)
Clinic Currently Attending(Required)

Date:____________________ Approved by:______________ ***Amount Approved***
Primary Caregiver Information(Required)
Product/Service Requesting for Reimbursement(Required)
Please add the reimbursement amount under each category that applies, up to a total of $750 (or remaining balance of your grant).
All receipts must be clear and have a full description of item/service and must be listed on the Eligible Expenses List.
Drop files here or
Max. file size: 10 MB.
    STOP: Before Submitting, Please make sure the following is Accurate(Required)
    MM slash DD slash YYYY