Fillable [Type here] UCA Food Pantry Enrollment Form Application (Utah Community Action)

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[Type here] UCA Food Pantry Enrollment Form Application (Utah Community Action)

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[Type here] UCA Food Pantry Enrollment Form Application Date
Revised Aug 2020
Head of
Household
First Middle Last
DOB Phone Number Zip Code
Gender Family Type
Disabling Condition Race
Ethnicity Health Insurance
Income Description Monthly Amount
Income
Total Monthly Income
Adult 2
First Middle Last
DOB Phone Number Zip Code
Gender Relationship to Head of Household
Disabling Condition Race Ethnicity
Health Insurance
Income Description Monthly Amount
Income
Total Monthly Income
Adult 3
First Middle Last
DOB Phone Number Zip Code
Gender Relationship to Head of Household
Disabling Condition Race Ethnicity
Health Insurance
Income Description Monthly Amount
Income
Total Monthly Income
Adult 4
First Middle Last
DOB Phone Number Zip Code
Gender Relationship to Head of Household
Disabling Condition Race Ethnicity
Health Insurance
Income Description Monthly Amount
Income
Total Monthly Income
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[Type here] UCA Food Pantry Enrollment Form Application Date
Revised Aug 2020
Family Member 5
First Middle Last
DOB Gender Relationship to Head of Household
Disabling Condition Race
Ethnicity Health Insurance
Family Member 6
First Middle Last
DOB Gender Relationship to Head of Household
Disabling Condition Race
Ethnicity Health Insurance
Family Member 7
First Middle Last
DOB Gender Relationship to Head of Household
Disabling Condition Race
Ethnicity Health Insurance
Family Member 8
First Middle Last
DOB Gender Relationship to Head of Household
Disabling Condition Race
Ethnicity Health Insurance
Family Member 9
First Middle Last
DOB Gender Relationship to Head of Household
Disabling Condition Race
Ethnicity Health Insurance
Family Member 10
First Middle Last
DOB Gender Relationship to Head of Household
Disabling Condition Race
Ethnicity Health Insurance
Family Member 11
First Middle Last
DOB Gender Relationship to Head of Household
Disabling Condition Race
Ethnicity Health Insurance
Family Member 12
First Middle Last
DOB Gender Relationship to Head of Household
Disabling Condition Race
Ethnicity Health Insurance
Family Member 13
First Middle Last
DOB Gender Relationship to Head of Household
Disabling Condition Race
Ethnicity Health Insurance
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[Type here] UCA Food Pantry Enrollment Form Application Date
Revised Aug 2020
*Self-declaration of income has been implemented due to a state of emergency. Required documentation of income will be
implemented when the state of emergency is lifted.
200% Federal Poverty Guidelines
1. Please refer to “200% Federal Poverty Guidelines” chart (left) and enter the “Monthly Income” amount
that corresponds to your family size into the “200% Federal Poverty Guidelines Monthly Income” field
below.
(For example, for 5 family members, you would select $5113 as your “Monthly Income”)
2. DO NOT ENTER into the “Total Monthly Income” field as it is auto-populated*.
3. DO NOT ENTER into the “Federal Poverty Limit %” field as it is auto-populated*.
* = Data is automatically calculated from other fields and populated into the appropriate total field
Persons in Household Monthly Income
1 $2127
2 $2873
3 $3620
4 $4367
5 $5113
6 $5860
200% Federal Poverty Guidelines Monthly Income
7 $6607 Total Monthly Income
8 $7353 Federal Poverty Limit %
For each additional, add +$747 Each I certify that my income falls under 200% of the federal poverty limit
I understand that this information is requested to determine eligibility for services that are paid for with Community Services Block Grant (CSBG) funds and that
intentionally giving misleading, inaccurate, or untruthful information may result in services provided by Utah Community Action (UCA) being terminated.
I understand that third-party verification is the preferred method of certifying income for assistance. I understand that self-declaration is only permitted when I
have attempted to, but cannot, obtain third party verification.
Date of Birth
Name
Signature
Date Signed
By entering my name above, I certify the information contained is correct and I agree to its content, and that the information I have provided is true.
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Completed 8 June 2021

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