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Application
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Please print, fill out and bring to us.
(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
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