Food Assistance Application Form
Effective 04/02/2025 Households may utilize the food pantry once every 60 days. Food boxes typically provide 2-4 days worth of food.
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date
Upload Copy of Id
*
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Attach copies of picture Id of anyone in household
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of
Upload Copy of Food Stamp Determination Letter
*
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Attach copies of picture Id of anyone in household
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of
Upload Copy of Current Bank Statement
*
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Attach copies of picture Id of anyone in household
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of
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How much money do the members of your household have in cash or in a bank account?
What is the total amount of income you expect your household to receive this month?
What is your current monthly rent/mortgage payment?
Have you or anyone in your household received or do you expect to receive Food Assistance benefits from any other county or any other state this month?
Yes
No
Household Members
Do you agree to the following participation statement
*
Please Select
Yes
No
Heavens Care participates in a client tracking program and will share client information with other agencies in our tracking system to avoid duplication of services. I hereby give Heavens Care permission to communicate with the central tracking agency and any other agency, church, or individual as necessary, to complete or verify my request for assistance. I understand that this information will be used only for the above-stated purpose and that this information will be confidential. Furthermore, I attest the information I have provided is accurate and correct to the best of my knowledge.
By Signing Clicking Yes on This Statement I Certify the Following
*
Please Select
Yes
No
(1) I am a member of the household living at the address provided in Section 1 and that, on behalf of the household, I apply for Foods that are distributed through The Emergency Food Assistance Program; (2) all information provided to Heavens Care determining my household’s eligibility is, to the best of my knowledge and belief, true and correct; and (3) if applicable, the information provided by the household’s proxy is, to the best of my knowledge and belief, true and correct.
Consent
I authorize and consent to collect and share all of my records, data, and information.
Signature
Submit
Submit
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