Fondy Food Pantry | Food Assistance

client information

First Name

last Name

County

do you have a current address at this time?YESNO

Gendermalefemaleopt out

date of birth

phone number

email address

Proxy name of person designated to pick-up food

Proxy's relationship to the client

does anyone in your household have special dietary needs? (check all that apply)nonediabetesallergiesother (Specify in notes)

how many in the household have these special dietary needs?

are you tefap eligible?

Eligibility Requirements can be found here.

YESNOunsure

compliance with federal equal opportunity programs

The information requested in the section below on this form and the application regarding race, ethnicity and handicapped status is needed to analyze and assure compliance with Federal Equal Opportunity laws and to meet the reporting requirements of those laws. Your cooperation in voluntarily giving this information is important to the success of our equal opportunity program.

languageenglishspanishotheropt out

ethnicityHispanic Not Hispanicopt out

Does anyone in your household receive FoodShare (food stamps)?Yes, we do.No. We've applied; We don't qualify.No. But we would like to apply.No. We don't wish to apply.

Do you consider anyone in your Household to be handicapped or disabled?yes Noopt out

The head of your Household is male or female?MaleNoopt out

PLEASE LIST ALL HOUSEHOLD
MEMBERS WITH THE
FOLLOWING INFORMATION:
‍
First Name
Last Name
Gender
Date of Birth

APPLICANT CERTIFICATION
AND SIGNATURES

With my approval above, I certify that the combined, gross income of all members of my household does not exceed the income eligibility limits posted in the food pantry on the date(s) I have signed. I attest that all persons I have listed on this form actually live in my household, and that these are the people with whom I will share this food. I understand that the food provided to us is for our use only. I release this food pantry and any agency or person distributing food from this pantry from any liability resulting from my receipt of this food. I certify that all information I have provided on this form is true and correct. I understand that false certification may require me to repay the value of the benefits I received and that I may also be subject to prosecution

I agree

Thank you! Your submission has been received!

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Your needs matter.

Walk-In Pantry

Home Delivery Service

First time? Register here.

client information

compliance with federal equal opportunity programs

Thank You to Our Supporters

Donate
Food

Donate
Funds

Your needs matter.

Walk-In Pantry

Home Delivery Service

First time? Register here.

client information

compliance with federal equal opportunity programs

Thank You to Our Supporters

DonateFood

DonateFunds

Donate
Food

Donate
Funds