Food Bank Registration (TEFAP)

Your Name*

First NameMiddle NameLast NameSuffix

Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your Phone Number*

Please enter a valid phone number.

Your Email*

Confirmation Emailexample@example.com

What County do you live in?*

You ARE NOT eligible to use this food bank unless you are a full time resident of Pinellas County, FL.

How many TOTAL people are in your household?*

How many family members do you have living with you full time?

The following shows a yearly gross income for each family size. If your household income is at or below the income listed for the number of people in your household, you are eligible to receive food.

The chart details eligibility criteria for monthly income, income received twice monthly (24 payments per year), income received every two weeks (26 payments per year) and weekly income.

You are eligible to receive food from TEFAP if your household meets the income guidelines above or participates in any of the following programs? Please place a checkmark in the space next to the category that applies.*

Income eligibilitySupplemental Nutrition Assistance Program (SNAP) (aka Food Stamps)Temporary Assistance to Needy Families (TANF)Supplemental Security Income (SSI)Medicaid

Date*

Date

Hour MinutesAM/PM Option

Are you a current registered volunteer at this CTKLM Food Bank?*

YES - I am a VolunteerNO - I am NOT a Volunteer

Are you a current registered volunteer?

Do you want to authorize another adult to pick up your Food Bank items?*

YESNO

If yes, what is their full legal name?

First NameMiddle NameLast NameSuffix

How EASY was this registration process?

1=Worst --- 5=Best

I agree to the terms and conditions

Your Signature*

Use your finger to sign if on a tablet/phone, otherwise use the mouse/mouse pad to sign.