Brockton Haitian Creole Bodega Application Form

Eligibility | Kalifikasyon

This form is in English & Haitian-Creole | Fòm sa a an Anglè & kreyòl
ENGLISH: At this time, only Brockton residents are eligible for this emergency fund.

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KREYOL: Nan moman sa a, se sèlman rezidan Brockton ki kalifye pou fon ijans sa a.
I verify that the applicant lives in the city of Brockton /Mwen verifye ke aplikan an ap viv nan vil Brockton . *

Yes/Wi NO/Non
Instructions | Enstriksyon
ENGLISH: The CPLAN Bodega Project is sponsored by The Boston Foundation. The fund was created to provide access to culturally responsive food to Brockton's diverse community while also supporting small local businesses. The fund offers residents who need food assistance with a food voucher from a local participating Bodega (grocery store) in their neighborhood. Once the application has been accepted, reviewed and approved, a CPLAN food voucher between $50-$100 (depending on family size) is sent by mail to be used at the selected bodega. Residents will be able to give this food voucher to the cashier to purchase the food and/or items they need (pampers, tooth paste, cough medicine, etc.). Applications are reviewed on a rolling basis and submitted by referrals. For consideration please complete the form below for yourself or someone you'd like to refer and if selected, someone from our team will be in touch with you.

KREYOL: Pwojè CPLAN Bodega a patwone pa Boston Foundation. Fon an te kreye pou bay aksè a manje ki gen bon kiltirèl nan divès kominote Brockton an pandan l ap sipòte tou ti biznis lokal yo. Fon an ofri rezidan ki bezwen asistans ak manje e yon bon manje ki sòti nan yon Bodega lokal k ap patisipe (makèt) nan katye yo. Yon fwa ke aplikasyon an te aksepte, revize ak apwouve, yon koupon manje CPLAN ant $ 50 - $ 100 (selon gwosè fanmi an) voye pa lapòs pou itilize nan bodega ke ou chwazi a. Rezidan yo pral kapab bay koupon manje sa a kesye a pou yo achte manje ak / oswa atik yo bezwen (pampers, keratin dan, tous medikaman, elatriye). Aplikasyon yo revize sou yon baz woule epi soumèt pa referans. Pou konsiderasyon tanpri ranpli fòm ki anba a pou tèt ou oswa yon moun ou ta renmen refere e si nou chwazi w ou byen moun nan, yon moun nan ekip nou an ap kontakte w ou byen moun ou ranpli fom lan pou li a.
Applicant's Information | Enfòmasyon sou aplikan an
Full Name | Non *

First Name | Non Last Name | Siyati
Address |Adrès *

Street Address | Ri

Apartment No. | Apatman No.

City | Vil State | Eta

Postal / Zip Code United States
Phone Number | Nimewo Telefòn *

Area Code | Aryèkòd Phone Number | Nimewo Telefòn
E-mail Adrès Imèl *
What is the best way for us to contact you? | Ki pi bon fason pou nou kontakte ou? *

Phone call /Apèl Telefòn Phone Text / Tèks Email / Imèl
What is the best time to reach you? | Ki pi bon lè pou nou rele w? *

: Hour Minutes AM/PM Option
Until
until : Hour Minutes AM/PM Option
Family Size | Gwosè Fanmi an

1 2-4 5-10
Which Grocery Store is best for you to shop or to pick up your payment? | Ki makèt ki pi bon pou ou pou w achte oswa pou ranmase peman ou? *

East Side Market, 364 Centre St, Brockton, MA 02302 Vicente's Supermarket, 689 Main St, Brockton, MA 02301 Vicente's Supermarket, 160 Pleasant St, Brockton, MA 02301
Is there someone else who will go shopping for you?Èske gen yon lòt moun ki pral al fè makèt pou ou? If yes, please write their full name on here. Si wi, tanpri ekri non konplè yo sou isit la.
Full Name of person shopping |Non konplè moun ki pral fè makèt la.
Electronic Signature of honesty | Siyati elektwonik Onètete .

ENGLISH: I have filled out this form honestly and understand that failure to do so will result in loss of funds and removal from the list. KREYOL: Mwen ranpli fòm sa onètman epi mwen konprann ke echèk pou fè sa ap lakòz mwen pèdi lajan ak retire nan lis la.
Should be Empty:

Eligibility | Kalifikasyon

Instructions | Enstriksyon

Applicant's Information | Enfòmasyon sou aplikan an