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Need Assistance

Note: MDFF is currently only assisting individuals and families in the state of Indiana.

Your name

Your email


Address 2




Birth date of person needing assistance

Have you been diagnosed by a physician to have a form of Muscular dystrophy?

Requested item/service

Do you have a written estimate?

If yes, please provide the dollar amount $

Description of how the requested item/service will provide assistance (e.g., how long has the need existed, and if need is not met, what are you ongoing limitations?)

If financial assistance from MDFF is not received, what is your plan to pay for this need?

I understand that by completing this information that additional documentation may be required including such items as bank statements, most recent tax return, and a record of related medical expenses

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