Phone Number

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are there children under 18 or elderly adults in your household?

Yes

No

Do you currently have any source of income?

Yes

No

Is your income fixed?

Social security, disability, etc

Yes

No

Have you recently lost income due to the government shutdown?

Yes

No

Have you gone without meals in the past week due to lack of food?

Yes

No

Do you currently have enough food in your home to last one week?

Yes

No

Do you receive EBT (food assistance) benefits?

Yes

No

Have your EBT benefits been delayed or reduced?

Yes

No

Do you know how to access a local food bank?

Yes

No

Have you visited a local food bank in the last 6 months?

Yes

No

Are there any special dietary needs in your household?

Yes

No

I affirm that the information I've provided is accurate to the best of my knowledge. I understand that assistance will be provided based on the level of need and available resources. *

Yes

Date *

MM

DD

YYYY