Secure Online Pantry Registration

Date

Name*

First NameMiddle NameLast Name

Date of Birth*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email

example@example.com

What method of communication do you prefer?*

Ok to Contact by email, text, and call.

Head of Household is a(n)*

AdultSeniorChild

Number of people in the household from age 60+

Number of people in the household from age 41-59

Number of people in the household from age 19-40

Number of people in the household from age 6-18

Number of people in the household from age 0-5

Please list all additional members of the household other than applicant. This is required information.

1. Name

First NameLast Name

Date of Birth

Race

Gender

2. Name

First NameLast Name

Date of Birth

Race

Gender

3. Name

First NameLast Name

Date of Birth

Race

Gender

4. Name

First NameLast Name

Date of Birth

Race

Gender

5. Name

First NameLast Name

Date of Birth

Race

Gender

Is anyone in your household currently receiving SNAP or food stamps?*

YesNoDon't know / Prefer not to answer

Does anyone in your household currently receive benefits through the following government programs? Select all that apply.*

Does your household meet the Income Eligibility Guidelines as defined by the Texas Department of Agriculture in the table above?*

YesNo

Job/Occupation*

Income*

MonthlyYearly

$ Amount*

Crisis Eligibility

Is this household in crisis?

Please explain the household crisis you are experiencing.

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g. Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA's TARGET Center at (202)720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800)877-8339. To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (866)632-9992 or by writing a letter addresssed to USDA. The letter must contain the complainants name, address, telephone number and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights; 1400 Independence Avenue, SW; Washington, D.C. 20250-9410; or (2) fax: (202)690-7442; or (3) email: program.intake@usda.gov. This institution is an equal ppportunity provider.

Gender identity: What gender do you identify as?*

Race and Ethnicity: What race and/or ethnicity do you identify as? Select all that apply.*

Language Spoken

Military Status: Has anyone in your household, including yourself, served on active duty in the U.S. Armed Forces? Active duty includes serving in the U.S. Armed Forces as well as activation from the Reserves or National Guard.

Yes, on active duty in the past, but not nowYes, now on active dutyNo, never on active duty except for initial/basic trainingNo, never served in the U.S. Armed ForcesDon't know / Prefer not to answer

How many people in your household, including yourself, are U.S. military veterans?

Employment status: In the last month, did you or anyone in your household work for pay full-time (for 36 hours per week or more)?*

YesNoDon't know / Prefer not to answer

Disability status: Does anyone in your household, including yourself, have a disability that prevents them from accepting any kind of work during the next six months?*

YesNoDon't know / Prefer not to answer

How many people in your household, including yourself, are disabled if any?*

"Within the past 30 days we worried whether our food would run out before we got money to buy more".

Often trueSometimes trueNever true

"Within the past 30 days, the food we bought just didn't last and we didn't have money to get more".

Often trueSometimes trueNever true

I hereby certify that: (1) I am a member or a proxy of the household living at the address provided and that, on behalf of the household, I apply for USDA foods that are distributed through The Emergency Food Assistance Program. (2) All information provided to the agency determining my household's eligibility is, to the best of my knowledge and belief, true and correct. I acknowledge that I may be prosecuted for making false statements related to the information I have provided for this application. *

Secure Online Pantry Registration

Household Members

TEFAP Eligbility

Demographics

Food insecurity