Grant Request Form ALS United North Carolina Care Grant - Request for Funds Form Person with ALS(Required) First Name Last Name Mailing Address(Required)If mailing address is a PO Box, you must provide a physical address below Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code County(Required)Physical Address (must provide if the above address is a PO BOX) Or different from mailing address Same as previous Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email(Required) Phone(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). Be sure you have checked the ALS Eligible Expenses List to confirm item/service you are submitting is on the list. If it is not on the list, you will not be reimbursed for that item/service and that payment will not be processed. Respite CareMedical ExpensesTransportationHome ModificationCommunicationTotal Amount Requesting(Required)Clinic Currently Attending(Required) Duke ALS Clinic Atrium Charlotte ALS Clinic UNC ALS Clinic ECU ALS Clinic Novant Greenville ALS Clinic Atrium Wake Forest Baptist ALS Clinic Other Primary Caregiver Information(Required) Name Relationship to person with ALS Address(Required) Street Address City State ZIP / Postal Code Email(Required) Phone(Required)Please Attach (Upload) All Eligible Receipts Below(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 MUST BE UPLOADED IN PDF FORMAT Drop files here or Select files Accepted file types: pdf, Max. file size: 10 MB. STOP: Before Submitting, Please make sure the following is Accurate(Required) My receipts are dated within the previous 12 months of this submission date. I HAVE checked the ALS Eligible Expenses List and the item/service is on that list Date is on or before the deadline of the period I am submitting as follows: 1st period (Jan 21 – July 20) deadline = July 20 & 2nd period (July 21 - Jan 20) deadline = January 20. Receipts have a CLEAR DESCRIPTION of the service and/or item purchased and include date of service/purchase and $ amount paid. (DO NOT SEND IN RECEIPTS WITHOUT DESCRIPTION) I have uploaded a COPY OF ACTUAL RECEIPTS. NOT cancelled checks, bank statements, credit card statements/receipts, insurance EOB (explanation of benefits), medical portal statements/account statements without clear description of service and charge, Quote, Estimate or Proposal – as these are NOT eligible types of receipts and cannot be reimbursed using these. 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)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. I agree to the above StatementDate(Required) MM slash DD slash YYYY Relationship to person with ALS (type "self" If person with ALS)(Required)Person Submitting Form (represents signature)(Required)CAPTCHA
