No More Empty Pots Food Support Application

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Thank you for your interest in No More Empty Pots food programs! The following form will help us determine eligibility for food at no cost to you through available funding. If you have any questions, contact Tanya at communityharvest@nmepomaha.org or call/text Tanya at 402.690.0888.

Email *

First Name *

Last Name *

Gender *

Primary Phone *

Secondary Phone

Address Line 1 *

Address Line 2

City *

State *

Zip *

Closest School *

What school is closest to you?

Communication Preference

Please check the types of communications that you are able to receive:

Phone call

Text message

Pick Up or Delivery *

If you are eligible, how would you like to receive your food? Pick up is on Fridays from 8-10am, Saturdays from 12-2pm, you may come either day. Delivery occurs on Saturdays and Sundays, you cannot choose your delivery day. Delivery is reserved for those without reliable transportation

Pick up

Delivery

Food Type *

What type of food would you like to receive?

Community Supported Agriculture box/produce box

Prepared meals

Both

Household Size *

Number of people receiving food:

Household Members *

All household members names AND BIRTHDAYS. Please include first and last names.

Referred by

If you were referred by a person or organization, please list them here.

Household Income *

What is your approximate yearly household income?

Cancer Survivor *

Are you or someone in your household a survivor of cancer?

Yes

SNAP Benefits *

Are you or someone in your household currently receiving SNAP benefits?

Yes

Food Security *

Select the statement that best describes your household:

We never or rarely have enough food and weren't aware of other resources to get food.

We never or rarely have enough food and utilize food stamps and/or pantries to get food.

We always or usually have enough food and occasionally utilize food stamps and/or pantries.

We always or usually have resources to purchase and prepare nutritious food.

We always or usually have resources to purchase and prepare nutritious food OF CHOICE.

Proof of Income *

Are you able to provide a letter showing ONE of the following proofs of income: Supplemental Security Income, Social Security, TANF/ADC, Section 8, Medicaid, Medicare, LIHEAP, CHIP, SNAP, WIC, V.A. disability, free/reduced lunch, childcare subsidies, OR the last two months worth of paystubs of for self-employed, bank statements?

Yes, I receive one of the above and can provide proof

No, I do not receive one of the above

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