I certify that the facts contained in this application are true and complete to the best of my knowledge, and I authorize verification of all statements contained herein. SIGNATURE DATE NAME _______________________________________________________________ ADDRESS ____________________________________________________________ CITY____________________ STATE _____ ZIP ________ COUNTY____________ DAY PHONE ____________________ ALTERNATE PHONE ___________________ E-MAIL ADDRESS __________________________ DATE OF BIRTH ___________ PHYSICIAN’S NAME ________________________ PHYSICIAN’S PHONE _______________________ DATE DIAGNOSED_________ MONTHLY GROSS INCOME $ ________________ MONTHLY EXPENSES $ _____________________ REQUESTED ITEM ____________________________________________________ ESTIMATED COST OF ITEM $_____________________ May we leave a detailed message about this application on your voice mail or with another household member, if you are not available? n Yes n No BRIGHTER TOMORROW GRANT In one page or less, explain how the Brighter Tomorrow Grant, of no more than $1,000 in goods or services, would help you have a brighter tomorrow. Additional paper may be used if needed, not to exceed one page. Please provide the doctor’s confirmation form, found on reverse side, verifying diagnosis of MS.