Senior Food Box Application

Benton Methodist Senior Box Program Application

Please fill out as much information as you can below to make your application process faster. We are a food pantry for Bossier Parish residents in Benton, LA. You need your Louisiana ID or DL, utility bill for proof of residence, and proof of income. If you need to find the pantry nearest you, please contact the NWLA Food Bank at 318-675-2400. If you need further information, please contact Rachel at 318-935-8515 before 2 PM Tuesday-Thursday. Distribution is on the 3rd Wednesday of each month from 1230-4 PM except in December when it will be the 2nd Wednesday.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Phone*
Please enter a valid phone number.
Email
example@example.com
Personal Information

Please enter your information
Date of Birth*

MonthDayYear
Date
Last 4 of Social Security Number
You can also give this in person at the church if you are uncomfortable filling this information out online.
Driver's License/ID State
Driver's License / ID Card Number
Must be a valid Louisiana license or ID Card
Please select ethnicity:*
Race (you may choose more than one):*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhite or Caucasian
Please see the USDA site for race and ethnicity data collection requirements for the CFSP (senior box program)

https://www.fns.usda.gov/cn/Race-and-Ethnicity-Data-Policy-Rescission
Alternate to Pick Up Food

Please add someone to pick up food in the event you are unable to make it here on pick up day. We also can make appointments after pick up day if you do not have anyone to come.
Alternate 1 Name
Alternate 2 Name
How do I qualify?

There is a maximum income requirement and age requirement for the supplemental senior box program (CFSP). Please enter your monthly income below so we can confirm your eligibility and bring to the church upon pick up and completion of your application.
Please enter monthly income*
Enter income
Family Information

Please enter information for each family member below
Name
Date of Birth

MonthDayYear
Date
Family Member Relationship
Name
Date of Birth

MonthDayYear
Date
Family Member Relationship
Name
Date of Birth

MonthDayYear
Date
Family Member Relationship
Name
Date of Birth

MonthDayYear
Date
Family Member Relationship
Name
Date of Birth

MonthDayYear
Date
Family Member Relationship
Name
Date of Birth

MonthDayYear
Date
Family Member Relationship
Name
Date of Birth

MonthDayYear
Date
Family Member Relationship
Name
Date of Birth

MonthDayYear
Date
Family Member Relationship
Should be Empty:

Benton Methodist Senior Box Program Application

Personal Information

Alternate to Pick Up Food

How do I qualify?

Family Information