Information Request Form

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

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 ADDITIONAL household members/Numero miembros adicionales 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.Format: (000) 000-0000.

Do you or anyone in your household receive SNAP benefits/Usted o alguien en su hogar recibe beneficios de SNAP?

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?

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?

Household Information