Clone of 2025 GOG Assistance Application

Graces of Gurley (GoG) Food Assistance Application 2025:

REQUIREMENTS FOR FOOD ASSISTANCE: You must have an active EBT/SNAP benefit account. You must live in the 35748 zipcode or have students who attend Madison County Elementary or Madison County High School. If you meet these requirements, complete this application truthfully and thoroughly. GoG reserves the right to deny applications with falsified information, based on GoG knowledge of families we serve. Applicants may or may not be allowed to correct falsified information. This is at the discretion of GoG.
Our first priority is to provide Weekend Food Bags for children, which will be distributed at school on Fridays to those who have completed an application. Our second priority will be family food boxes, which will be given out at Graces of Gurley. You will be notified of the days and times you may pick up food boxes. Please understand that while we do our very best to help every family in need, we cannot make any guarantees. All of our assistance depends on the generosity of donors who make it possible for us to serve our neighbors.
I'm applying for:
Parent/Guardian/Adult Name:*

First NameLast Name
Spouse/significant other living in same household (If none, enter Not Applicable)*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
First Child's Name

FIrst & Last NameGradeDate of Birth
Second Child's Name

FIrst & Last NameGradeDate of Birth
Third Child's Name

FIrst & Last NameGradeDate of Birth
Fourth Child's Name

First & Last NameGradeDate of Birth
Fifth Child's Name

FIrst & Last NameGradeDate of Birth

MONTHLY HOUSEHOLD EXPENSES*

	Payment Amount
Rent
Utilities/Propane
Phone
Medical
Car payment(s)
Insurance
Loans
Spousal Support
Child Care
Furniture
Food/Necessities
Credit Card(s)
Cable/Internet
Other

Total Household Expenses Calculation:
Landlord's name and phone number (if applicable):
What is the last 2 digits of your EBT card? Type NA if you do not receive SNAP*
When is the last date you received SNAP benefits for food? Select today's date if you do not receive SNAP*

MonthDayYear
Date
How much money did you receive for SNAP on your last EBT card? Type NA if you do not receive SNAP*

INCOME SOURCES (you must list everyone living with you). Put the number 0 in column one if the category does not apply. Put N/A in column two if the category does not apply:*

	Parent/Guardian	Spouse/Other Adults 18 & over
Place of Employment
Weekly/Monthly Salary
Food Assistance/SNAP
Child Support
WIC
SSI/Disability
Spousal Support
Other

Total Income Calculation
Total number of people residing in household:*
For elderly/disabled, are you eligible for SSA/SSI/SSD? If so, do you receive it?
If not, please explain above
If you are unemployed, are you receiving unemployment? *
If not, please explain above
I certify that the information provided on this application is accurate. I understand that withholding of information or giving false information may result in a refusal of services by Graces of Gurley. I understand it is my repsonsibility to inform Graces of Gurley if any information in this application changes and that this information may be shared with other community partners to help better serve you.
First Name Last Name Date
Signature*

Clear
Should be Empty:

Graces of Gurley (GoG) Food Assistance Application 2025: