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Allegany County Cancer Services, Inc.
                          "In Allegany County ... For Allegany County"

                                                       Application Form and  Requirements
                                       To qualify for a gas card from ACCS the following guidelines must be met:
1. You must be a resident in Allegany County, New York with fulltime residential proof to be provided a $600.00 gas card.

2.  Your cancer diagnosis within 2 years of application submittal that is noted and signed by medical representative on Physician Verification form.  

3.  You cannot have Medicaid - if you do have Medicaid, please check with your rep in Allegany County Social Services about travel reimbursement.

4.  Proof of Allegany County residency and identity may consist of current driver's license, non-driver identification, utility bill with address, military ID, or similar forms of identification.

4.  Since March of 2011, ACCS can only provide a one time award of a gas card because of the large volume of applicants.

5.  The Application Form as shown on this website will be the only application accepted and must be fully completed per guidelines listed above to be considered and processed.

Application Form
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