Organization Name (submit completed form for each individual):

AID Recipient's Name: Street:

City, State, Zip:

Daytime Telephone: Fax Number: Email Address:

Aid Requested: $ Address where aid is to be sent:

LEGIBLE COPY OF INCIDENT REPORT MUST BE MAILED OR FAXED FIRST! OTHERWISE REQUEST WILL BE DENIED!

Firefighters Charitable Foundation Inc.
One West Street, Farmingdale, New York 11735
Fax: 516-249-0338

Provide in the space below detailed description of incident, including date and location.
The RECIPIENT of AID must be the person DIRECTLY AFFECTED IN THE INCIDENT REPORT!