Information Request Form

Household Information

Informacion de hogar
Do you live in Ellis County/Vives en el condado de Ellis?*

Yes/SiNo/No
Waxahachie Care currently only services Ellis County. To find a local food pantry, please visit https://ntfb.org/food-assistance/find-a-food-pantry/.

Waxahachie Care actualmente solo presta servicios en el condado de Ellis. Para encontrar un banco de alimentos local, visite https://ntfb.org/food-assistance/find-a-food-pantry/.
Name of household member/ Nombre del miembro de la unidad familiar*

First NameLast Name
Address(if available)/Direccion (si disponible)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number/Numero de telefono*

Area CodePhone Number
Number of Household members/Numero de miembros del hogar*
NOT INCLUDING YOURSELF/SIN INCLUIRSE A SI MISMO
Name of Proxy/Nombre de apoderado:
PERSON YOU AUTHORIZE TO PICK UP IN YOUR PLACE/PERSONA QUE USTED AUTORIZA PARA REPRESENTARLO
Phone Number of Proxy/Numero de telefono del proxy:
Please enter a valid phone number.
Do you or anyone in your household receive SNAP benefits/Usted o alguien en su hogar recibe beneficios de SNAP?*

Yes/SiNo
Do you or anyone in your household receive any of the following assistance or benefits/Usted o alguien en su hogar recibe alguna de las siguientes ayudas o beneficios?*

Childcare Assistance/Asistencia de cuidado infantilSSISSI Disability/SSI DiscapacidadUnemployment/DesempleoCHIPHeadstart/VentajaMedicaid/Seguro de enfermedadPublic Housing/Vivienda publicaFree/Reduced school meals/Almuerzos escolares gratuitos o de precio reducidoMedicare/Seguro medico del estadoTANFWIC
Applicant e-mail address/ correo electronico*
example@example.com
Waxahachie Care is an Equal Opportunity provider. Do you agree that you have willingly provided this information/Waxahachie Care es un proveedor que ofrece igualdad de oportunidas. Acepta haber proporcionado voluntariamenta esta informacion?*

Yes/SiNo/No
Should be Empty:

Household Information