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Application for North Carolina Home Modification Grant Program

Personal Information

1. Please enter your primary contact information.
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Financial Information

Upon completion of your form, a National MS Society staff member or agent will request documentation of your household income.

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Income Sources:

Please enter dollar amounts below.

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Medical Insurance

19. Field Is Required Please select the appropriate response(s):
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Nature of Request

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30. Field Is Required The above information is complete and true to the best of my knowledge. By submitting this application, I give the National MS Society permission to obtain any further information relevant to this assistance request.

Additional documentation or information may be requested to determine how best to address this request.


Applicants who satisfy the published eligibility criteria and the terms and conditions set forth by the state of North Carolina for the Home Modification Grant Program have an equal opportunity to be selected. The Society will make decisions without regard to race, color, religion, age, sex, national origin, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, or North Carolina laws.

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