Applicant Name

Street Address

Email

City/Town

Zipcode

Primary Phone

Alternate Phone

Mailing Address (if different) Applicant will need One Proof of Residence (where you live, not PO Box)

Income Eligibility Please X next to the number of people in your household.

Income Income 1 Person - $36,144 2 People - $49,056 3 People - $61,968 4 People - $74,880 5 People - $87,792 6 People - $100,704 7 People - $113,616 8 People - $126,528 9 People - $139,440 10 People - $152,352

Is your household TOTAL Yearly Income less than the amount next to the family size? Is your household TOTAL Yearly Income less than the amount next to the family size? Yes No

Program Eligibility Please X all assistance programs that any household member is eligible for or currently receiving.

Program Program Food Stamps SSI Medicaid / Children's Medicaid SSDI Subsidized Housing (Rental Subsidy) Aid to Permanently and Totally Disabled (APTD) Fuel Assistance / Electric Assistance Temporary Assistance to Needy Families (TANF) Women, Infants and Children (WIC) Commodity Supplemental Food Program Free/Reduced School Meals Assistance County, City or Town Welfare You do not need to be receiving assistance to qualify.

Household Information Please list ALL members of household beginning with Applicant

Applicant Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Signature The above information is true and correct. I understand that this will be kept confidential and is needed to verify my household eligibility to receive food each week. This food is not to be sold or exchanged. SaveClear

Date