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.

Copies of itemized bills, receipts, estimates, rental agreements or leases must accompany the application for it to be considered.

Applications may be submitted:

electronically via the form below
via email to blcs1813@gmail.com, with scanned documents attached
Printed forms and receipts may also be mailed to: BLCS, P.O. Box 943, Southport, CT 06890

Name of Organization/Agency

Contact's Full Name

Contact's Address

Contact's City & State

Contact's Email Address

Contact's Phone Number

Beneficiary's First Name

Beneficiary's Town/City
* Please enter the town/city where the beneficiary resides.

Amount of Request ($)
* Please submit copies of itemized bills, receipts, or estimates if applicable.

If approved, check should be made payable to:
* Checks are NOT made payable directly to the beneficiary. Please enter a payee name for the check.

Items Requested
*Please be specific in your requests regarding clothing, household items, etc.

Individual's situation and need
*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.

Attach itemized bills, receipts or estimates here: