Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Do you have lupus or are applying on behalf of a lupus patient? *

Yes, I have lupus or am applying on behalf of a lupus patient

No

Have you applied for an Emergency Grant from the MI Lupus Foundation in the past? *

Yes

No

Do you have health insurance?

Yes

No

Do you currently receive public benefits?

Yes

No

Grant Request (please check one) *

Documentation required. Grant funding will be paid directly to the service provider.

Medical necessity: durable medical equipment, prescription medication, etc.

Assistance with outstanding medical bills: a copy of the outstanding medical bill must be provided

Assistance with outstanding utility bills: a copy of the outstanding utility bill must be provided

I acknowledge that all information is true and accurate. I understand that if it is discovered that I have falsified any of the information above, my grant request will be denied. *

I agree

I understand there is no guarantee that a grant will be awarded, approval is subject to fund availability within the MI Lupus Foundation. *

I understand

I agree to submit all requested information to info@milupus.org in order for the grant to be considered. *

I agree

Date

MM

DD

YYYY