Fillable Food Pantry Intake And Verification Form (Cuba Township)

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Food Pantry Intake And Verification Form (Cuba Township)

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U.S.A. forms for Cuba Township

BROWSE CUBA TOWNSHIP (IL) FORMS

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Cuba Township Food Pantry
Intake and Eligibility Verification Form
*Applicant must be a Cuba Township resident with a valid ID, Proof of residency and proof of income for the
last 30 days.
Resident
Spouse
Name: _________________________________
Name: __________________________________
DOB: __________________________________
DOB: ___________________________________
Address: ________________________________
Address: ________________________________
City: ___________________________________
City: ____________________________________
Phone: ____________________
Phone: _______________________
Email: _____________________
Email: ________________________
Occupation: _____________________________
Occupation: _____________________________
Employer: _______________________________
Employer: _______________________________
*Please list all others living in household
Name
M/F
DOB
Age
Relationship
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Below list income for ALL members residing in household. Income includes gifts, personal loans or monies
received as beneficiary of a Trust.
Income for a 30-day period Expenses for a 30-day period
Unemployment $________________ Rent/Mortgage $__________________
Social Security $________________ Utilities $__________________
SSI $________________ Vehicle loans $__________________
Veteran Benefits $________________ Loans $__________________
Retirement Benefits $________________ Other ___________ $__________________
Gross Wages $________________ Other ___________ $__________________
Child Support $________________ Other ___________ $__________________
Trust funds/Gifts $________________ Other ___________ $__________________
Total monthly income $________________ Total monthly Expense $__________________
LINK or SNAP (Yes or No) $_______________ Subsidized Housing (yes or no) Rent $__________
I declare myself eligible to receive assistance and/or food products and that the information provided is true.
I will inform Cuba Township of all changes to residency and income in a timely manner. I understand that I will
be required to provide evidence of information that I have provided and that failure to comply will result in my
ineligibility of services.
I understand that all information provided to Cuba Township staff is kept confidential and will be shared with
other agencies only with my consent either verbally or in writing.
I acknowledge that the selling or trading of items that I have received will deem me ineligible for assistance.
I understand the Cuba Township Food Pantry does not guarantee the quality or the condition of items
provided.
I agree to hold harmless all Cuba Township employees, elected officials, trustees, volunteers, counselors and
directors from and against any and all losses, damages, costs, charges, legal fees, recoveries, judgments,
expenses, or penalties which may arise, be obtained against, imposed upon, or suffered by them which they
sustain, incur, or be required to pay as a result of bodily injury, death or property damage or in any matter
connected with, directly or indirectly by receiving assistance for my own use or benefit of any family member,
friend or associate use.
S
ignature _____________________________________ Date _____________________
Signature _____________________________________ Date _____________________
Signature _____________________________________ Date _____________________
Intake by ______________________________________ Date _____________________
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Food Pantry Intake And Verification Form (Cuba Township)

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Completed 15 July 2020

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