Insurance Information:

Are the applicant’s medical bills covered in part by any of the following

Employment Information

**If applicant is a child, the information above must be supplied by both parents.**

Financial Information:

To assure that our financial assistance is provided to those individuals with the greatest need, it is crucial that a copy of our most recent family’s 1040 Income Tax Return including all schedules and statements be submitted with your application.

Other Assistance:

Please Note: All the information appearing on this application will be treated in the strictest confidence. Any inaccuracies will automatically disqualify the applicant from consideration. The decision of the Philanthropic Committee will be final. Publication of the relative merits of the candidates will not be made. I, by the submitting below, attest to the truthfulness of all the statements made in this application and understand the contents thereof.
Address all correspondence and return all applications to: Charles Pedrani Philanthropic Chairman 248 Madison Avenue Wyckoff, NJ 07481