Snap survey

*NOTE: All information gathered in this survey is confidential and names will not be stored with other data or with your SNAP Application. We use this demographic data to ensure we’re serving the underrepresented families in our service area.
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
May we use this number to text you?*

YesNo
Best Time to Call*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Would this be your first time receiving SNAP?

YesNo
If NO, is this application a recertification?

YesNo
Would you consider your household a rural household?

YesNo
Does your head of household have current employment?

YesNo
Would your head of household consider themselves Hispanic?

YesNoPrefer not to say
What would your head of household consider their race to be? Choose one or more:

Alaskan Native/Native AmericanAsianBlack/African AmericanPacific Islander/Native HawaiianWhitePrefer not to sayOther
How were you referred to us? Choose one:

InternetPaper brochure/Information packetReferralFood PantryOther
How many children under 18 live in the household?
How many seniors 60 and over live in the household?
How many people in your household are applying for SNAP?
Based on the number of people in your family, is your income more than the Annual Yearly Income Poverty Limit in the below chart?

YesNo
May we use this information for our data tracking?*

YesNo
Should be Empty: