Hultman Memorial Fund

The ULF Family Assistance Program

Overview

Thanks to a generous donation by the Hultman family, the ULF has established a memorial fund that is intended to provide financial assistance to leukodystrophy-affected families who are struggling to pay expenses directly related to the affected family member.

Eligibility

To be considered, a family must complete and submit an application form and demonstrate:

• Financial hardship – includes but not limited to; change in income, medical related expenses, and overall financial need.  Note: Detailed information supporting the need, related to the affected family member, must be included.
• Proof of USA Residency – US citizenship is not required, but we are only granting funds to USA residents.
• Proof of leukodystrophy diagnosis – examples include a letter from a physician, test results with diagnosis noted in comments, etc.

Grant Details

• Grants will vary based on the financial need/ situation.
• A max of $500.00 USD, per affected family, is allowed per grant.
• Funds will be sent via a hard-copy written check.
• A family can receive no more than one grant in a 12-month period.   

Important Notes

• Applications will be reviewed by the Hultman Committee four times per year. Deadline dates to apply are: March 31, June 30, September 30, and December 31.
• Families that receive a grant are not eligible for an additional grant for one rolling calendar year, and each application will be considered separately.
• The information and documentation that families submit will not be shared beyond the ULF managing staff.
• Questions about the Hultman Family Assistance Program should be directed to the ULF Office via email at [email protected].

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone *

Email *

Are you a resident of the U.S.A.? *

• Yes
• No

Citizenship is not required; we are only able to mail funds to people who reside in the U.S.A.

What type of leukodystrophy is your family affected by? *

Your affected family member(s) first and last name(s), or "self" if you are the affected person. *

Your relation to the affected family member(s), or "self" if you are are the affected person. *

Please attach documentation of the leukodystrophy diagnosis for your family member(s) or yourself, blocking out social security information or other sensitive information: *

Click or drag files to this area to upload. You can upload up to 5 files.

Up to 5 file uploads allowed, must be .jpg, .jpeg or .pdf

Please provide any additional documents that support your request (photos, time cards, work schedules, etc.), blocking out social security information or other sensitive information.

Click or drag files to this area to upload. You can upload up to 5 files.

Up to 5 file uploads allowed, must be .jpg, .jpeg or .pdf

Please provide details that explain the need for financial assistance. This may include but is not limited to family income, expenses not covered by insurance, and cost of overall care for the affected person/people. *

Submit