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

• Grant amounts vary based on each family’s financial need and individual circumstances.
• The maximum grant amount is $500 USD per affected family, per grant.
• Priority consideration is given to families who have not previously received assistance through this program.
• Funds are issued via a hard-copy check.
• A family may receive no more than one grant within a 12-month period.

Important Notes

• Applications are reviewed on a rolling basis as funding is available.
• Families that receive a grant are not eligible for an additional grant for one rolling calendar year. Each application is reviewed and considered independently.
• The information and documentation submitted by families will remain confidential and will not be shared beyond ULF managing staff.
• Questions about the Hultman Family Assistance Program should be directed to the ULF Office via email at office@ulf.org.

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