Application

 
(Please Print)
First Name:  _____________________M.I.___  Last Name:  _________________________                      
Nickname: _________________________________Date of Birth:  _________________________
Street Address:  __________________________________________________________________
City: ________________________________Zip: ________________County:  _________________
Phone Number: Home: Cell:  __________________________________________________

(Circle One)
Source of Income:   Social Security     Disability     SSI      Child Support      Wages      Family Support
Amount of Income: (monthly) ____________ Do you receive SNAP Benefits?   Yes  or   No
How many people in the household are employed? __________
(Circle One)
Gender:    Female        Male         Transgender        Do not identify as Male, Female, or Transgender
Ethnicity:  Caucasian(white)    African-American    Asian    Hispanic     Marshallese    Native American    Middle Eastern      Multiracial       Other ___________
Education Completed:    CollegeHigh School/GED             Some College       High School Incomplete

Employment:    Full-Time          Part-Time         Unemployed     Retired

Marital Status:  Divorced           Married     Separated   Single    Widowed

Residential Status:     Own               Rent            Homeless              Transient             At-Risk of Being Homeless

Would you like anyone to pick up food for you if you are unable? If so, please give their name(s):_____________

I, ______________ authorize ________________ to be my Authorized Representative and pick up my TEFAP products.


I, ____________________ understand misrepresentation of need, and the sale, exchange or misuse of commodities is prohibited and could result in a fine, imprisonment or both. I am aware my application may be selected for verification. I will cooperate should my application be selected. I am not receiving USDA foods from another source.


    (Turn Over)
Please List All Household Members (excluding yourself):
         First & Last Name                  Date of Birth                     Ethnicity                 Relationship          Income Source & Amount