HEAD OF HOUSEHOLD *

First Name

Last Name

ANY CHANGE TO STREET ADDRESS?

NO CHANGE TO STREET ADDRESS

YES - SEE BELOW

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

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. HOUSEHOLD SIZE YEAR MONTH WEEK 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