SCAIR Food Distribution Eligibility Form 2022
Please compete this form prior to receiving your gift card.
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First Name *
Last Name *
Middle Initial
Gender *
Street Address *
City *
State *
Zip Code *
Date of Birth *
Phone Number *
Email Address *
I certify the following: *
You will sign this document when you come to pick up your aid. Please check this box now for digital verification.
Required
County *
I reside off-reservation in the following county:
Tribal TANF Office / Tribal Office
Please leave this question blank if you do not use Tribal TANF.
My tribal affiliation is: *
I have health insurance *
If you answered "Yes" to health insurance, please select the option that best describes you.
Clear selection
Sources of Income: *
Please select ALL that apply
Required
If you selected "Other," please specify:
Please select ALL that apply
If you selected "Non-Cash Benefits," please specify:
Please select ALL that apply
Approximate Income *
2021 Poverty Guidelines
Household Type *
Household Size
Housing *
Education Level *
Ethnicity *
Military Status *
Work Status *
Please acknowledge the following: *
Required
Submit
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