Grant Request Form

ALS United North Carolina Care Grant - Request for Funds Form

Complete 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 MUST include a description of service/purchase and all other 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 provide if the above address is a PO BOX) Or different from mailing address
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).
Clinic Currently Attending(Required)

Primary Caregiver Information(Required)
Address(Required)
All receipts must be clear and have a date, amount paid, place of purchase information (company name, address, phone number) and a CLEAR DESCRIPTION of item/service and on the ALS Eligible Expenses List. Receipts need to be uploaded in PDF format.
Drop files here or
Accepted file types: pdf, Max. file size: 10 MB.
    STOP: Before Submitting, Please make sure the following is Accurate(Required)
    By submitting this Care Grant Request for Funds and signing below, I assume personal responsibility for understanding the ALS United North Carolina Care Grant Request for Funds process, eligible expenses, and hard deadlines. If ANY OF THE ABOVE IS NOT ACCURATE, I understand that I will not receive reimbursement for these items. I also understand that no exceptions will be made to the grant deadlines and all grants are subject to availability of funds. If false information is provided, I understand that ALS United NC has the right to refuse reimbursement of funds and also if I submit the same receipts more than once, I will be no longer eligible for the ALS United North Carolina Care Grant.(Required)
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