The Emergency Food Assistance Program Application

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Please complete the following form.

Name *

Address *

Zip Code *

# of family members in household *

Categorical Eligability- Check all that apply

SNAP: Supplemental Nutrition Assistance Program

TANF: Temporary Assistance for Needy Families

SSI: Supplemental Security Income

NSLP: National School Lunch Program

Medicaid

Annual Gross Family Income

Household Crisis- Check all that apply

COVID 19

Loss of wages/ hours

Other

Phone Number

Hispanic/Not Hispanic

Yes

Clear selection

Race

White

Black/African American

Asian

American Indian/Native American

Hawaiian or Pacific Islander

Black/African American + White

Asian + White

Other Pacific Islander

Other Multi-racial

Clear selection

The information provided on this form is subject to verification by HUD at any time, and Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department of the United States Government. I hereby certify that all information within this survey is true and correct to the best of my knowledge.

Yes

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Submit

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