2021 Newmarket Community Church Food Pantry Assistance Program (Newmarket, New Hampshire, USA)

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The information collected here is for statistical reporting ONLY, allowing us to acquire USDA food. Information provided will NOT affect your ability to access food from the pantry or affect your eligibility for any of the below listed programs.

Name: *

Address: *

Home Phone Number:

Cell Phone Number:

Email Address:

How many people are living in your household? *

Do you have any of the following pets in your household?

Dog

Cat

Do you have vehicle? *

Yes

Other:

Please list the name, birthdate, and relationship (spouse, child, etc) of each household member (including yourself):

Please list an emergency contact (name and phone number): *

PROGRAM ELIGIBILITY: Are you or any member of your household currently eligible for and/or are receiving help from the following programs? Please check all that apply.

Fuel Assistance

Women, Infants and Children (WIC)

Commodity Supplemental Food Program (CSFP)

Temporary Assistance to Needy Families (TANF)

Old Age Assistance

Head Start

Food Stamps

Medicaid

Aid to the Needy Blind

Subsidized Housing (Rental Subsidy)

Aid to Permanently /Totally Disabled (APTD)

County or Town Welfare

INCOME ELIGIBILITY: ls your gross yearly household income at or below the following guidelines? (Note: If you placed a check mark next to at least one of the above programs you DO NOT have to complete this section)

Yes

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