FINANCIAL ASSISTANCE GRANTS
MSHH Financial Assistance Grants
are now available
You need to complet the forms required (See Below)
Financial Assistance Grants for Durable Medical Equipment (DME)
and Mobility Equipment (ME) are also available
"Financial Assistance Grants" are only
available to people with Multiple Sclerosis who reside in the
State of Washington. Due to the large demand for financial
assistance grants currently being received, we will only provide
financial assistance grants to a person with MS once a year.
We will also provide these grants first to those who haven't
already received one over a request from someone who has already
received one in order to help more people. After they have been
helped, we will than process grants for others as funds become available.
For people with Multiple Sclerosis who are requesting financial assistance
and who reside outside the State of Washington, contact:
Multiple Sclerosis Foundation
6520 North Andrews Ave
Ft Lauderdale, FL 33309
Administrative Offices,
Fund Raising, Donations, Advertising
Call toll-free (within USA): 800-225-6495
or Fort Lauderdale area 954-776-6805
(9 am – 5 p.m. Eastern Standard Time)
Fax: 954-351-0630
E-mail:
admin@msfocus.org
Website: http://www.msfocus.org
Since 1999 MSHH has awarded over $300,000 in
financial assistance or medical equipment grants to people
with MS who reside in the State of Washington.
To qualify for a financial assistance grant, a letter from your doctor is required
to verify that the applicant - client - has been diagnosed with having
Multiple Sclerosis and comlete the forms provided..
Financial assistance funds are made available from: the minimum suggested donations
for the Durable Medical Equipment (DME) & Mobility Equipment (ME) items recycled
from the Donor Closet, memorial donations, special events, donations received
from individuals, various grants, and from the MSHH Sucker Trays.
FINANCIAL ASSISTANCE GRANTS UP TO $1,500 PER REQUEST
ARE AWARDED ON A TWELVE (12) MONTH CYCLE.
(If you receive financial assistance in April 1, 2011, then you qualify again after April 1, 2012)
FINANCIAL ASSISTANCE GRANTS WILL BE PROVIDED
TO PEOPLE WITH MULTIPLE SCLEROSIS FOR:
HOUSING (Late/Overdue Rent, Mortgage Payments, Utilities, & Phone Bills),
FOOD (Gift Cards),
MEDICAL (Doctors, Hospitals, Clinics & some Medicines),
&
DME/ME ITEMS in the MSHH Donor Closet with proof of having MS.
The financial assistance grants are paid directly to whom they are owed.
You are required to provide a copy of the bills with your request for
financial assistance that you intend to pay with your grant.
Other emergency requests or amounts are evaluated on an individual basis.
Bills not covered by MSHH financial assistance grants include:
Credit Card Debt, Cable TV – Internet, Recreation/Entertainment,
Cigarettes, Alcohol, Drugs, Vacations & Travel Expenses,
and money for other members of your family.
Allow up to 30 Days for approval of your request.
Do not wait until the last minute to apply for financial assistance.
We will contact you by telephone regarding your request and if we are
unable to contact you after 5 days of trying, your request will be denied.
You are required to respond to MSHH by mail within
10-days after receiving your financial assistance grants.
Remember, these financial assistance grants are often nothing more than a band aid
to help solve your immediate financial problems. It is recommended that you contact legal
aid or some other social service agency to assist you in getting the financial
assistance you need in order get into a program that you can afford and live with.
Call (425) 712-1804 or E-mail info@mshelp.org in order to receive a
financial assistance grant form & for further information.
NOTE: Financial Assistance grants
are only available to people with
Multiple Sclerosis who reside in the
State of Washington
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MSHH HELPING HANDS -MSHH
"FINANCIAL ASSISTANCE GRANT REQUEST FORM"
TO RECEIVE FINANCIAL ASSISTANCE YOU MUSTRESIDE IN THE STATE
OF WASHINGTON
You are required to provide a letter from your doctor stating that you have Multiple Sclerosis.
Please print your answers & answer all questions.
DATE:
NAME:
MALE: FEMALE:
ADDRESS:
CITY: STATE: ZIP:
OWN: RENT: JUST STAYING/LIVING THERE:
PHONE: ( )
CELL PHONE: ( )
E-MAIL ADDRESS:
DOES APPLICANT HAVE MULTIPLE SCLEROSIS: YES NO
BIRTHDATE:
SOCIAL SECURITY NUMBER:
MARITAL STATUS: MARRIED: SINGLE: WIDOW/ER:
DIVORCED: SEPARATED:
DATE ORIGINALLY DIAGNOSED:
SYMPTOMS SINCE:
DOCTOR’S NAME:
PHONE NUMBER: ( )
CURRENT DOCTOR’S NAME:
PHONE NUMBER: ( )
NUMBER OF CHILDREN LIVING WITH YOU? AGES:
CURRENTLY WORKING: YES ____ NO ____
EMPLOYER:
ADDRESS:
CITY: STATE:
PHONE NUMBER: ( )
YOUR POSITION:
CURRENTLY LOOKING FOR WORK: YES ____ NO ____
ARE YOU ABLE TO WORK? YES ____ NO ____
REASON FOR BEING UNABLE TO WORK:
CURRENT SOURCE OF OTHER INCOME: (You & Your Spouse)
HAVE YOU APPLIED FOR AND BEEN REFUSED FINANCIAL ASSISTANCE FROM
OTHER SOURCES? IF SO, WHO, WHEN AND THE REASON FOR BEING REFUSED?
HAVE YOU RECEIVED FINANCIAL ASSISTANCE FROM MSHH BEFORE? IF SO WHEN,
HOW MUCH & WHAT FOR?
TOTAL AMOUNT BEING REQUESTED: $
REASON FOR FINANCIAL ASSISTANCE REQUEST?
(Provide copies of bills to be paid)
IF POSSIBLE, DO YOU PLAN TO PAY BACK THE REQUEST FOR FINANCIAL
ASSISTANCE BEING PROVIDED? YES: NO: IF SO, WHEN & HOW:
ANY ADDITIONAL FORMATION YOU CARE TO PROVIDE:
IF MORE SPACE IS NEEDED, ATTACH A SEPARATE PAGE:
You are required to provide a letter from your doctor stating that you have Multiple Sclerosis.
Provide copies of the bills you intend to use this grant for.
PLEASE ALLOW UP TO 30 DAYS FOR EVALUATION APPROVAL
RETURN REQUEST TO:
MS Helping Hands – MSHH
(FINANCIAL ASSISTANCE)
9792 Edmonds Way, #229
Edmonds, WA 98020
Fax: MSHH - (425) 776-1712
(09/01/2011)