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The Emergency Food Assistance Program (TEFAP)
Household Eligibility Criteria Form
Distribution Site: ChristWay Christian Church
Distribution days: Monday, Wednesday, and Friday, weekly
Distribution times: 10 AM - 11 AM
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* Indicates required question
Last Name
*
Your answer
First Name
*
Your answer
Physical Address (N/A if homeless)
*
Your answer
Phone number (xxx)xxx-xxxx (N/A if None)
*
Your answer
County of Residence
*
Choose
Col
Rich
Other
How many persons are in your family?
*
Choose
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
How many in your household are 60 or older?
*
Choose
0
1
2
3
4
5
6
How many in your household are under 18?
*
Choose
0
1
2
3
4
5
6
7
8
Names and Ages of Household Members under 18 (Format: First Name, Last Name, Age in 1 line)
Your answer
GNAP Eligible? (food stamps, free lunch, section 8, low income, other)
Choose
Yes
No
Authorized Representative (Person allowed to pick up for my household, if any).
Your answer
Type/Batch# of today's box (internal only)
Your answer
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