Application For Food Distribution Form - 2013 printable pdf download

Application For Food Distribution Form - 2013

FOR OFFICE USE ONLY:

I.D.

LOCATION:

DATE RECEIVED:

APPLICATION FOR FOOD DISTRIBUTION

You may complete this form at home and mail, fax, or email it in or bring it to the office. Or, another member of your

household or an adult who knows you may complete and return it to us with your permission.

IMPORTANT: When you are interviewed, please bring proof of all household income (pay stubs, award letters, copies of

You must provide proof/verification of all income and allowable deductions.

checks, etc.)

Name (Head of Household):

Tribe:

Mailing Address:

Household Size:

City/State/ZipCode:

Telephone No.:

Residence Address/Directions

HOUSEHOLD MEMBERS: Complete the following for each member of your household. Your household means yourself and the people

who live with you. List your name first. (Attach a separate sheet if you need to list additional household members.)

RELATIONSHIP TO HEAD

DATE OF

NAME(S) OF ALL HOUSEHOLD MEMBERS

OF HOUSEHOLD

SOCIAL SECURITY #

BIRTH

(Last, First, Middle Initial) . Please Print.

(self, spouse, daughter, son, cousin etc.)

Are you or anyone in your household currently receiving SNAP (Food Stamp) benefits?  Yes  No If yes, list names:

Have you or anyone in your household recently applied for SNAP (Food Stamp) benefits?  Yes  No If yes, list names:

Have you or anyone in your household been disqualified from the Supplemental Nutrition Assistance Program (SNAP) [Food

Stamps] for an intentional program violation?  Yes  No. If yes, list name(s):

 Yes  No If yes, list names:

Are you or anyone in your household currently receiving SSI with a food allowance?

1220 Blosser Lane Willits, California 95490 ~ Phone: 707-456-1710 or 1712 ~ Fax: 707-456-1714

E-mail: sherwoodvlyfdpir@sbcglobal.net

Application For Food Distribution Form - 2013