Request Form

If you live in Durham, Lee, Madbury, or Newmarket and need financial assistance, please work with a community validator who is familiar with your situation. A community validator could be a school nurse, guidance counselor, teacher, doctor, hospice worker, clergy member, or a worker at a social service agency. This validator can certify your status and help you determine the specific amount to request.

For Validators Only: please complete each line as all information will be used in assessing your request. We can only provide assistance to a client once in a 12 month period. If you are having difficulty accessing our form, please contact us via the Contact page.