Application for Assistance

Applications are by referral only, from local agencies and community or religious organizations. They will be considered at the Managers' monthly meetings, held on the first Wednesday of each month, and are due by the Friday preceding the meeting.

Applications may be submitted electronically or by printing and mailing this form to:

P.O. Box 320132
Fairfield,  CT  06825

Please enter the name of the organization or agency who is making the request.
Contact person information
Beneficiary information
Please enter the first name only of the intended beneficiary.
Please enter the town/city where the beneficiary resides.
Please submit copies of itemized bills/receipts/estimates if applicable. They can be mailed to BLCS, P.O. Box 32132, Fairfield, CT 06825 or scanned and emailed to
Checks are NOT made payable directly to the beneficiary. Please enter a payee name for the check.
Please be specific in your requests regarding clothing, household items, etc.
Please use this space to give us a brief description of the individual's situation and the reason for his/her need. This will be helpful in our decision-making process.