APPLICATION FOR ASSISTANCE / SOLICITUD DE ASISTENCIA
Applicant’s Name (Last, First, Middle) Nombre del Solicitante (Apellido, Nombres)
ARE YOU A VETERAN? YESNO
DATE OF BIRTH:
SECTION 1 - APPLICATION - TO BE COMPLETED BY THE HOUSEHOLD MEMBER
By signing below, I certify that
1. I am a member of the household living at the address provided in Section 2 and that, on behalf of the household, I am applying for food assistance;
2. All information provided to the agency determining my household’s eligibility is, to the best of my knowledge and belief, true and correct; and:
3. The information provided by the household’s “Authorized Representative” (as named below or as authorized on a separate page) is also, to the best if my knowledge, true and correct.
SECTION 2 - HOUSEHOLD INFORMATION/NUMERO DEL HOGAR:
HOW MANY PEOPLE IN YOUR HOUSE? CRISIS ELIGIBILITY:
Are you receiving FOOD assistance from another organization? YESNO
If yes, what organization?
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: email@example.com. This institution is an equal opportunity provider.
Sites may request but must not require proof of information. / Los sitios pueden solicitar pero no deben requerir prueba de información
HOUSEHOLD INCOME – MONTHLY:
DO YOU RECEIVE ANY OF THE FOLLOWING (CHECK ALL)
DO YOU HAVE ANY DIETARY RESTRICTIONS? YESNO
Disclaimer: All product is donated and all items are accepted in an "as is" condition.
Only the information collected on the H1555 can be requested for a participant to obtain USDA Foods.