pantry applicationPlease fill out the information below and a team member will contact you before our next distribution. When I arrive at the pantry, I will provide a photo ID and agree to sign this application to certify that the statements are true and correct. * I agree I disagree Name * First Name Last Name Phone * (###) ### #### Email Address * Address 1 Address 2 City State/Province Zip/Postal Code Country How many people live in your household? * What is your total household income? * This amount is: * Weekly Monthly Annual Does your family receive any type of assistance? * Check all that apply TANF (Temporary assistance to needy families) SSI NSLP SNAP (Food stamps) Medicaid Temporary Assistance We do not receive any assistance. DEMOGRAPHIC INFORMATION Please select your race American Indian or Alaska Native Asian Black or African American Hawaiian or Pacific Islander White Hispanic Military Status * Active Military Retired Reserve Veteran No military status How many people in your house are ages 0-5? * 6-18 years * 19-40 years 41-59 years * 60+ years Household Composition * Two parents with child(ren) Single parent with child(ren) Single adult Senior living alone Other Check any category that applies to you or your family: * Check all that apply Physically disabled Mentally disabled Victim of abuse Chronic illness Homeless None of the above My signature will be required to certify that my yearly household gross income is true and correct, or that I participate in the program that I have checked on this form. I also certify that as of today, I reside in the state of Mississippi. The certification is being submitted in connection with the receipt of assistance. Program officials may verify what I have certified to be true. I understand that making a false certification may result in having to pay the agency for the value of the food improperly issued to me and may subject me to civil or criminal prosecution under state and federal law. * I agree I disagree Thank you!
