Apply for Food Assistance

Applicant’s Name (Last, First, Middle) Nombre del Solicitante (Apellido, Nombres)

, TX

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?

WHAT CRISIS OR SITUATION IS PROMPTING YOU TO NEED GROCERY ASSISTANCE AT THIS TIME?

Are you receiving FOOD assistance from another organization? YESNO

If yes, what organization?

HOUSEHOLD INCOME – MONTHLY:

DO YOU RECEIVE ANY OF THE FOLLOWING (CHECK ALL)
SNAPTANFSSINSLPMEDICAID DISABILITY

Have you had a grocery card with Harvesting in the past? (asistencia pasada)
YESNO

DO YOU HAVE ANY DIETARY RESTRICTIONS? YESNO

Disclaimer: Some of our products are donated and accepted in an “as is” condition.