SWANSEA COUNCIL ON AGING HELPING HANDS FOOD CUPBOARD Please take a moment to answer all questions so that we may serve you better. We are required to obtain the following information from our clients for funding and reporting purposes. CLIENT DOCUMENTATION (Please print clearly) New Client: ___YES ___NO (Office Use Only) Today’s Date Existing Client: ___YES ___NO SECTION A First Name: MSC ID # Last Name: Address: City: Home Phone: Zip Code: Cell Phone: Type of ID: Driver’s License Valid passport State identification card Birth Certificate Military ID Marriage license Immigration Services (USCIS) documents Citizenship or Naturalization certificate *Social Security Cards are not an acceptable form of identification. Type of address verification: A copy of electric bill A current piece of postmarked mail *Addresses on Driver’s Licenses are not always a reliable source for current address information. HOUSEHOLD INFORMATION (Please answer all questions) SECTION B Total # of individuals living in your household: ____ Total # of adults ages 18 to 55 in your household: _____ Total # of seniors over age 55 in your household: _____ Total # of children under age 18 in your household: _____ I certify all statements are true and accurate to the best of my knowledge and that, as of today are living in my household and will benefit from services provided by this organization. APPLICANT SIGNATURE DATE How would you best describe your employment status? (Please check all that apply) Employed Unemployed Retired Disabled Is this your first time receiving food this year? YES NO What is your estimated TOTAL HOUSEHOLD monthly income? $ Student SECTION C DEMOGRAPHIC INFORMATION Which best describes your household? (Please check one) Single parent, HOH (female) Single parent, HOH (male) 2+Adults w/children 2 parent family Single Adult(s) Married (no children) Optional – How would you best describe yourself? (This section is optional and used solely for funding purposes, it will not affect services you receive today.) African American Asian American Hawaiian/ Pacific Islander Native American Other Bi-Racial Hispanic Caucasian/White Multi-Racial SECTION D GENERAL QUESTIONAIRE (Please check all that apply) Are you homeless? Are you disabled? YES YES NO NO Please check all public benefit programs you are currently participating in: SNAP (former food stamp program) WIC LIEAP (energy assistance) Medicaid/Medicare Section 8 (housing assistance) Social Security CHIP (Children’s Health Insurance) School Meals (Free & Reduced Priced Lunches) Senior Commodities Farmer’s Market Coupons Unemployment Insurance Other: APPLICANTS MUST CERTIFY THEIR TOTAL HOUSEHOLD GROSS INCOME; TOTAL INCOME MUST MEET FEDERAL POVERTY LEVEL GUIDELINES TO RECEIVE THE EMERGENCY FOOD DISTRIBUTIONS. CURRENT GROSS ANNUAL INCOME MEANS INCOME THAT YOU ARE GETTING NOW, FROM ALL SOURCES, SUCH AS RENTAL INCOME, A JOB, GOVERNMENT ASSISTANCE, SOCIAL SECURITY, PENSIONS, ALIMONY, CHILD SUPPORT PAYMENTS, INTEREST ON SAVINGS, ETC. SECTION E TOTAL NUMBER OF MEMBERS IN HOUSEHOLD MEMBER NAME Total Income of Members TOTAL MONTHLY INCOME SOCIAL SECURITY NUMBER INCOME SOURCE UNDER 18 Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N SECTION F CERTIFICATIONS     I certify that I have included and named ALL household members in the home. I certify that I have included ALL sources of income for all household members in the home. I certify all statements are true and correct to the best of my knowledge. I certify that as of today, my household lives in the area served by the Swansea Council on Aging Food Cupboard Program (The Cupboard).  I understand making a false certification may result in having to pay The Cupboard for the value of the food improperly issued to me and may subject me to criminal prosecution under State and Federal Law.  I understand it is my responsibility to inform this organization of any changes. APPLICANT SIGNATURE DATE (For Office Use Only) WITNESSED BY: / DATE: (FOOD BANK OFFICIAL’S SIGNATURE) (PRINT LAST NAME) AUTHORIZED BY: _______________________________/________________DATE: ___________ HOUSEHOLD ELIGIBLE FROM (May be certified up to 12 months) TO DATE DATE This form must be completed by every participant and renewed in January. Please use the attached form for monthly income self-certification signatures each time clients receive food distributions. These applications are subject to review by the Swansea Council on Aging Food Cupboard Program and Department of Health and Human Services. NOTES: FAMILY NAME: _________________________________ DISTRIBUTION RECEIPT DATE FOOD PACKAGE RECEIVED PARTICIPANT SIGNATURE STAFF AUTHORIZATION