P.O Box 2316

Southampton

Phone Number

Dedicated to helping families and indivuals on the East End of Long Island for over 10 years

Your Custom Text Here

Recipient Information

Recipient Name

First Name

Last Name

Recipient Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Applicant Information

Applicant Name

First Name

Last Name

Applicant Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Relation to Recipiant

Phone

(###)

###

####

Location

the recipient lives in...

Which Life Necessity Is Needed?

Food

Shelter

Heating

Clothing

Medical

Other*

*If Other Please Indicate Below