House of Hope

CHECKLIST FOR ONGOING PANTRY ASSISTANCE LISTA DE DOCUMENTOS REQUERIDOS PARA LA ASISTENCIA DE COMIDA
All applicable information must be submitted for consideration for ongoing services by this date:
(Month)
(Day)
(Year)
A. Proof of Martin County Residency:
• Current Lease, property tax bill mortgage statement
AND
• Current utility bill (FPL, Water, Gas) (must be dated within the past 60 days)
Proof of Martin County Residency:

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B. Photo ID for ALL members of the household 18 yrs or older:
• Photo ID (i.e. driver's license, state ID-from any state, passport)
AND
• Birth Certificates for Children 17 years old and under
Photo ID for ALL members of the household 18 yrs or older:

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c. Proof of Program Eligibility:
Your eligibility is determined based on your financial status and current situation. House of
Hope reserves the right to require further documentation to determine program eligibility.
• Proof of ALL household income for past 30 days
► Employment Wages
► SS - SSI-SSDI*
► Pension (Retirement)*
► Veteran Benefits*
► Workman's COMP
► Unemployment
► Cash Assistance (aka TANF/AFDC)*
► Child Support
• Proof of Participation in a government assistance program, where applicable
► Supplemental Nutrition Assistance Program (SNAP) (aka Food Stamps)*
► Medicaid*
► Women, Infant & Children (WIC)*

*MUST provide current benefit award letter(s)
House of Hope does not and shall not discriminate on the basis of race, color, religion
(creed), gender, gender expression, age, national origin (ancestry), disability, marital
status, sexual orientation, or military status, in any of its activities or operations.
Toda la informaci6n solicitada para la consideraci6n de los servicios solicitados, deben ser entregados antes de esta fecha:
(Dia):
(Mes):
(Ano):
A.Prueba de residencia del condado de Martin:
• Contrato de arrendamiento actual, declaraci6n de la hipoteca del impuesto a la propiedad
y
• Factura actual de servicios publicos (FPL/ Luz, Agua, Gas) (La factura debe ser de entre las ultimas 60 dfas.)
File Upload

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B. ldentificaci6n con foto para TODOS los miembros del hogar de 18 anos o mayor:
• ldentificaci6n con foto (Par ejemplo: licencia de conducir, identificaci6n del estado-de cualquier estado, Pasaporte}
y
• Certificados de nacimiento para ninos menores de 17 anos de edad
File Upload

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C.Prueba de elegibilidad para el programa*:
Su elegibilidad sera determinada basado en su estado financiero y situaci6n actual. House of Hope se reserva el derecho de solicitar documentaci6n adicional para determinar la elegibilidad del
programa.
• Comprobantes de TODOS las ingresos del hogar durante las ultimas 30 dfas
► Salarios Laborables
► lngreso de Segura Social (SS, SSI, SSDI}*
► Pension (Retiro)*
► Beneficios de Veteranos*
► Compensaci6n del trabajador
► Desempleo
► Asistencia temporal para familias necesitas*
(Tambien conocida coma asistencia en efectivo (TANF/ AFDC}
► Manutenci6n de ninos
• Prueba de participaci6n en un programa de asistencia del gobierno, cuando sea applicable
► Programa de asistencia nutricional suplementaria (SNAP) (Tambien conocida coma
estampillas de comida}*
► Medicaid*
► Programa para mujeres, infantes y ninos (Conocido coma WIC}*

* DEBE PROVEER LA CARTA ACTUAL DE SUS BENEFICIOS
House of Hope no discrimina ni discriminara par motivos de raza, color, religion (credo), genera, expresi6n; edad, nacionalidad, discapacidad, estado civil, orientaci6n sexual o estado militar, en ninguna de sus actividades u operaciones
CHECKLIST FOR ONGOING PANTRY ASSISTANCE LISTA DE DOCUMENTOS REQUERIDOS PARA LA ASISTENCIA DE COMIDA
Client Intake Form
Name

First NameMiddle NameLast NameSuffix
HOH Branch Location
Main Contact Information
Name

First NameMiddle NameLast NameSuffix
Address

Address

Street Address Line 2

CityState

Zip
Mailing Address (if different from above)

Address

Street Address Line 2

CityState

Zip
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell/Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relation
Household Information:
Family Type:

Other
Housing Status:

Other
Primary Language:
How long have you lived in Martin County?
How long have you lived at your current address?
Please mark reason for seeking services:

Other
Head of Household Member Information

Please fill out information for person named above
Date of Birth (mm/dd/yy):

MonthDayYear
Date
Current Age:
Email:
example@example.com
Gender:

Other
Marital Status:

Other
Employment Status:
Ethnicity:
Race:
Primary Language:
Veteran Status:
Disabling Condition:
Education:
Income Source:

Other
Head of Household Member Information

(Please fill out information for other household members)
Household Member Profile 1:
Name

First NameMiddle NameLast NameSuffix
Relationship to Head of Household:

Other
Date of Birth (mm/dd/yy):

MonthDayYear
Date
Current Age:
Email:
example@example.com
Gender:

Other
Marital Status:

Other
Employment Status:
Ethnicity:
Race:
Primary Language:
Veteran Status:
Disabling Condition:
Education:
Income Source:

Other
Household Member Profile 2:
Name

First NameMiddle NameLast NameSuffix
Relationship to Head of Household:

Other
Date of Birth (mm/dd/yy):

MonthDayYear
Date
Current Age:
Email:
example@example.com
Gender:

Other
Marital Status:

Other
Employment Status:
Ethnicity:
Race:
Primary Language:
Veteran Status:
Disabling Condition:
Education:
Income Source:

Other
Household Member Profile 3:
Name

First NameMiddle NameLast NameSuffix
Relationship to Head of Household:

Other
Date of Birth (mm/dd/yy):

MonthDayYear
Date
Current Age:
Email:
example@example.com
Gender:

Other
Marital Status:

Other
Employment Status:
Ethnicity:
Race:
Primary Language:
Veteran Status:
Disabling Condition:
Education:
Income Source:

Other
Household Member Profile 4:
Name

First NameMiddle NameLast NameSuffix
Relationship to Head of Household:

Other
Date of Birth (mm/dd/yy):

MonthDayYear
Date
Current Age:
Email:
example@example.com
Gender:

Other
Marital Status:

Other
Employment Status:
Ethnicity:
Race:
Primary Language:
Veteran Status:
Disabling Condition:
Education:
Income Source:

Other
Household Size and Income Information

Please select the household size that applies to the NUMBER of persons in your household.

Household Size	Annual	Monthly	Bi-Monthly (24 pay periods)	Bi-Weekly (26 pay periods)	Weekly
1	$31,300	$2,608	$1,304	$1,204	$602
2	$42,300	$3,525	$1,763	$1,627	$813
3	$53,300	$4,441	$2,221	$2,050	$1,025
4	$64,300	$5,358	$2,679	$2,473	$1,237
5	$75,300	$6,275	$3,138	$2,896	$1,448
6	$86,300	$7,191	$3,596	$3,319	$1,660
7	$97,300	$8,108	$4,054	$3,742	$1,871
8	$108,300	$9,025	$4,513	$4,165	$2,083
For each additional family member add:	$11,000	$917	$458	$423	$212

Please circle the household size which applies to the NUMBER of persons in your household
Household Income Information
(GROSS = Total prior to any deductions, e.g., taxes, health insurance, etc.)

Household Income Information

Rows	Household Member Name	Source of Monthly Income	Frequency of Income	Gross Income Amount ($)
1
2
3
4
5
6

TOTAL HOUSEHOLD INCOME

Monthly Household Expenses Information:

Rows	Expense Amount ($)
Rent/Mortgage
Electric
Water
Gas (home)
Food
Medical (health related)
Car Payment
Car Insurance
Gas (auto)
Insurance (home, life, etc.)
Cable
Furniture
Child Care
Personal
Loans
Laundry
Credit Card(s)
Cell Phone
Other

Total Expenses ($).
APPLICANT STATEMENT

I/We affirm that I/we have read/had read to me/us, the information on this application for assistance and that the information I/we have provided has been properly recorded. I/we certify that the application information provided is true and complete to the best of my/our knowledge. I/we also understand that falsification or misrepresentation of the information recorded is just cause for denial of services and prosecution of fraud. I/we consent to the disclosure of information for the purpose of income verification related to making a determination of my/our eligibility for program assistance. I/we agree to provide any documentation needed
to assist in determining eligibility. Applicants that knowingly provide false, misleading or incomplete information will result in denial of application and barred from services from this program.

I/We understand that House of Hope may be required to collect some personal information by law or by organizations that provide funds to operate this program. Other personal information collected is important to run agency programs to improve services that House of Hope provides.
*The Applicant and Co-Applicant must sign below.
Applicant Signature
Date

MonthDayYear
Date
Co-Applicant Signature
Date

MonthDayYear
Date
Additional Information
1. Is your rent or mortgage current?
2. If no, are you currently in foreclosure or being evicted at this time?
a. If YES, how many months behind are you?
Living Expenses

Utilities:
3. Are you current on your electric bill?
4. Are you current on your water bill?
5. Are you current on your gas (house) bill?
Food:
6. Do you receive SNAP benefits (aka Food Stamps)?(Your answer does not affect your eligibility to receive food from the Food Pantry)
a. If YES, what is the amount of the benefit? ($)
b. If NO, have you applied for the SNAP benefits?
7. Within the past 12 months I/we worried my/our food would run out before I/we received money to buy more.
8. Within the past 12 months, the food I/we bought just didn’t last and I/we didn’t have money to buy more.
9. How many food pantries (including this one) do you visit a month?(Your answer does not affect your eligibility to receive food from the Food Pantry)
Health Insurance:
10. Do all adults in your family/household have health insurance?
11. Do all children in your family/household have health insurance?
Signature:
Date:

MonthDayYear
Date
Household Pet Information:
Do you own any pets?

If YES, please complete the following information.

Rows	Name	Species	Breed	Sex (M/F)	Age	Weight (lbs)	S/N (altered?)
1
2
3
4
5
6

For Dogs, Cats & Rabbits Only
Would you be interested in free spay/neuter for your pets?
Would you be interested in free vaccinations? (Pet must be 4 months or older)
Does your pet need a MICROCHIP?
Any existing conditions:
PET OWNER PROGRAM ELIGIBILITY
Pet owner MUST meet program eligibility for House of Hope services to qualify for the FREE Spay & Neuter Program offered through the Humane Society of the Treasure Coast Inc. and/or any other pet clinics made available.
Signature of Pet Owner:
Date:

MonthDayYear
Date
Should be Empty:

CHECKLIST FOR ONGOING PANTRY ASSISTANCE LISTA DE DOCUMENTOS REQUERIDOS PARA LA ASISTENCIA DE COMIDA

CHECKLIST FOR ONGOING PANTRY ASSISTANCE LISTA DE DOCUMENTOS REQUERIDOS PARA LA ASISTENCIA DE COMIDA

Client Intake Form

Main Contact Information

Household Information:

Head of Household Member Information

Head of Household Member Information

Household Member Profile 1:

Household Member Profile 2:

Household Member Profile 3:

Household Member Profile 4:

Household Size and Income Information

*The Applicant and Co-Applicant must sign below.

Additional Information

Living Expenses

Food:

Health Insurance:

Household Pet Information:

For Dogs, Cats & Rabbits Only

PET OWNER PROGRAM ELIGIBILITY