FAMILY INFORMATION UPDATE

We are utilizing a new system and are requesting you complete this updated form. Your information is always kept private & secure. Your name will not be shared with your data. Address and phone are optional.

Much of the information is required by organizations we are working with to bring you fresh produce & newer products you are seeing at the pantry. It will also help the pantry in several ways.

Better tracking system
We can apply for more funding with more accurate details of the families we are serving
If you have an urgent need or emergency situation arise, we have an immediate snapshot of your family & can jump into action.
It will prevent you from having to register this full amount of information each week & instead register will just an assigned number. Making the process easier for everyone.

HEAD OF HOUSEHOLD

First Name

Last Name

STREET ADDRESS (optional)

CITY

STATE

ZIP

COUNTY

Phone (optional)

(###)

###

####

Number of Adults over 60

Number of Adults 18-59

Number of Kids Under 18

HOUSEHOLD INCOME

No matter how you answer this question, you will still be able to visit our pantry, please answer honestly & accurately. Federal Guidelines for emergency assistance are below. The first column is household size, the second is yearly income, the second is monthly, third is weekly. 1 $30,120 $2,510 $580 2 $40,880 $3,407 $787 3 $51,640 $4,304 $994 4 $62,400 $5,200 $1,200 5 $73,160 $6,097 $1,407 6 $83,920 $6,994 $1,614 7 $94,680 $7,890 $1,821 8 $105,440 $8,787 $2,028 9 $116,200 $9,684 $2,235 10 $126,960 $10,580 $2,442 FOR EACH ADDITIONAL HOUSEHOLD MEMBER ADD $10,760 $897 $207

My household falls within these guidlines

My household does not fall within these guidlines

I'm willing to deliver a box to a neighbor near me.

Within 1 mile

On my street

Not at this time