Cache Community Food Pantry

Cache Community Food Pantry

Food Assistance Application

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Date

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Print Last Name First Name of Spouse

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Street Address City State Zip Code

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Telephone # Social Security # Gender: M F

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Date of Birth (mm/dd/yy) Age

Ethnicity (Race)Household TypeHousing

Native American/Alaskan______Two Parent w/children _____ Rent $______

Asian ______Female Single Parent _____ Own$______

Black ______Male Single Parent _____ Share $______

White ______Single Adult no children _____ Subsidized $______

Hispanic ______Multiple Adult no children _____ Utilities included Y or N

Pacific Islander ______Senior Citizen ______

Other ______Multiple Household _____ Name of Landlord

EmploymentOther Assistance

Place:______Food Stamps$______Social Security$_____

Hours per Week______SSI$______Pension$_____

Hourly Wage______AFDC$______Disability$_____

Monthly Gross Income______Child Support$______Other (explain)$_____

Check Stub ____Unemployment$______Medicaid$_____

Proof of Address____W.I.C.$______Worker’s Comp.$_____

Others Working

Who:______Where:______Monthly Gross $_____

Who:______Where:______Monthly Gross$_____

Additional Household Members

Name AgeBirthdayGenderSS # Disabled

______M or F______Y or N

Are any other members of your household receiving help from this Food Pantry? ______

Authorization to release case records, documents and other pertinent information.

I authorize the Department of Workforce Services (DWS) to release to the CACHE COMMUNITY FOOD PANTRY any records concerning household size, employment, and food stamp use past and present. I hereby designate CACHE COMMUNITY FOOD PANTRY as an authorized representative to review my case record and any other records that any organization may have concerning my case. I understand that by signing this form I am authorizing a release to CACHE COMMUNITY FOOD PANTRY information that is otherwise confidential. I understand by signing this form I hereby relieve said agency of any damages or injury that may result from the release of information.

As a client of the CACHE COMMUNITY FOOD PANTRY, you will receive food from the pantry during this year and will inspect said food to determine that it is fit for human consumption. Also, that 1. The food is accepted “as is”. 2. The CACHE COMMUNITY FOOD PANTRY and the ORIGINAL DONOR disclaim any implied warranties of merchantability or fitness for a particular use. 3. There have been no expressed warranties to this gift of food. 4. As a client you release both the ORIGINAL DONOR and the CACHE COMMUNITY FOOD PANTRY from any reliability resulting from the condition of the donated food and further agree to indemnify and hold the CACHE COMMUNITY FOOD PANTRY and the ORIGINAL DONOR free and harmless against all and any damages, liabilities, losses, claims, causes of action and suites of law or in equity or obligation whatsoever rising out of or attributed to any action of said client in connection with it’s storage and use of the donated food. 5. You will not sell or offer this food for sale, this is prosecutable by law. We reserve the right to refuse service to anyone.

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Client Signature Date

Do not print below this line. Office use only.

Date______

Comments______

Other related files______