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Emergency Food Registration Form
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* Indicates required question
Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
Birthdate
*
MM
/
DD
/
YYYY
Street Address
*
Your answer
Town & Zip Code
*
Your answer
Phone Number
*
Your answer
E-mail address
*
Your answer
Number of adults in household
*
Your answer
Number of children under 18 in household
*
Your answer
Qualifying Reason
*
TANF (Temporary Assistance for Needy Families - Social Services Program)
SNAP/Foodstamps Ran out/insufficient
SNAP/Foodstamps Lost
SNAP/Foodstamps Stolen
SNAP/Foodstamps Not received
SSI (Supplemental Security Income) - NOT SOCIAL SECURITY
WIC (Women, Infants, and Children)
MEDICAID
LOW INCOME (185% of poverty)
DISASTER (Other - can be divorce, domestic violence, unusual expenses, loss of employment)
Required
If DISASTER, please explain
Your answer
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