Food Distrbituion Form.xlsx

	A	B
1	Location Date	Location Date
2	Name/Nombre	Name/Nombre
3	Does this client have an A Number (Hay número de inmigrante)? Yes No Uncsure	Does this client have an A Number (Hay número de inmigrante)? Yes No Unsure
4	DOB/Fecha de Nacimiento	DOB/Fecha de Nacimiento
5	Proxy/Apoderado:	Proxy/Apoderado:
6	Have you been impacted by COVID 19 Yes No	Have you been impacted by COVID 19 Yes No
7	Phone#/Numero de Telefono	Phone#/Numero de Telefono
8	Email/Correo Electronic	Email/Correo Electronico
9	Address/Dirección	Address/Dirección
10	Zip Code/Codigo Postal	Zip Code/Codigo Postal
11	Race (Caucasian, Asian, Hawaiian, African American, Native American, Multal-Racial, Alaska Native, Other)	Race (Caucasian, Asian, Hawaiian, African American, Native American, Multal-Racial, Alaska Native, Other)
12	Ethnicity: Hispanic, No Hispanic, N/A	Ethnicity: Hispanic, No Hispanic, N/A
13	Sex (M/F)	Sex (M/F)
14	Su hogar es un hogar encabbezado por una mujer? Si No Is your household a female-headed household? Yes No	Is your household a female-headed household? Yes No
15	Primary Language (Spanish, English, Other, Refused to Answer)	Primary Language (Spanish, English, Other, Refused to Answer)
16	Country of Origin Pais De Origen	Country of Origin Pais De Origen
17	Marital Status (Single, Married, Separated, Divorced,Widowed)	Marital Status (Single, Married, Separated, Divorced,Widowed)
18	Household Annual Income/ Ingreso Annual Familiar ($20,000-$25,000; $25,000-$30,000; $30,000-$35,000; $35,000-$40,000)	Household Annual Income/ Ingeso Annual Familiar ($20,000-$25,000; $25,000-$30,000; $30,000-$35,000; $35,000-$40,000)
19	Household Size:____ Adults/Adultos (18-59___ Children/Ninos (0-17) ____ Seniors/Mayor de (60+) __	Household Size:____ Adults/Adultos (18-59___ Children/Ninos (0-17) ____ Seniors/Mayor de (60+) __
20	Cash or Non-Cash Benefits/Beneficios//Recibe algun benefio del gobierno	Cash or Non-Cash Benefits/Beneficios//Recibe algun benefio del gobierno
21	SNAP (Supplimental Nutrition Assistance Program)	SNAP (Supplimental Nutrition Assistance Program)
22	TANF (Temporary Assistance for Needy Families	TANF (Temporary Assistance for Needy Families
23	SSI (Supplemental Security Income)	SSI (Supplemental Security Income)
24	NSLP (National School Lunch Program)	NSLP (National School Lunch Program)
25	Medicare	Medicare
26	Medicaid	Medicaid
27	Other	Other
28	By Signing below, I, the applicant, Certify and Acknowledge that the information provide here will be used to determine my eligibility, and is true and correct to best of my knowledge. I understand that this information is subject to verification, and falsification of this information may be grounds for termination from the program and result in prosecution under federal and state laws.	By Signing below, I, the applicant, Certify and Acknowledge that the information provide here will be used to determine my eligibility, and is true and correct to best of my knowledge. I understand that this information is subject to verification, and falsification of this information may be grounds for termination from the program and result in prosecution under federal and state laws.
29	Applicant's Signature:___________________________________________________________	Applicant's Signature:___________________________________________________________
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