PLEASE PRINT, Answer ALL Questions, Completeboth Sides, and SIGN Back of Form

207 Washington Street, Wellesley, MA 02481 (781) 235-1188 / 2016-17 REGISTRATION FORM
check one: New Renewal
check if applicable:WHAhousing Other subsidized
housing (non-WHA)

PLEASE PRINT, answer ALL questions, completeBOTH sides, and SIGNback of form

Ms. Mrs. Mr. ______

Applicant first name (middle initial)Last name

Ms. Mrs. Mr. ______

Spouse first name (middle initial) Last name

______WELLESLEY MA ______

Street address (verification required) Zip E-mail address

______

Home phone Cell phone Language spoken at home

If you do not speak English, please provide the name, relationship, and phone number of someone we can contact in case of questions:

______

Marital Status: Single Married Divorced Widowed Separated

Ethnic Background: African Arab Asia/Pacific Caucasian Hispanic Multi-cultural Other ______

Rent/monthly $ ______Own/monthly mortgage $ ______Monthly utilities + other household expenses: $ ______

______$______

Employed? (Y/N) Employer Gross Pay Pay Period Work phone

______$______

Spouse employed? Spouse’s employer Gross Pay Pay Period Spouse’s work phone

Is your household receiving any of the following aid? Check all that apply: Food Stamps (SNAP) Welfare (TAFDC)

Section 8 WIC Fuel Assistance SSI Mass Health Unemployment

Please itemize all income sources and amounts for all household members not previously listed (income documents required):

______

TOTAL HOUSEHOLD INCOME: ______on a weekly monthly or annual basis.

The Wellesley Food Pantry serves any Wellesley household in need of supplemental food. Please explain any special circumstances that may be contributing to your situation.

______

*** Please turn over to complete other side of form.***

Total number in household: ____ Number of children under 18: ____

Please list ALL household members:

ADULTS (18 and over) M/F Date of Birth CHILDREN(under 18) M/F Date of Birth

____________

I am a shut-in because of my health and require delivery. Please explain:______

______

The above registration is true and correct. The Wellesley Food Pantry reserves the right to require additional financial information. I will notify the Wellesley Food Pantry if my circumstances improve significantly or my household changes.I understand that Wellesley Housing Authority staff will verify this information, if applicable.

APPLICANT SIGNATURE______DATE ______

PLEASE RETURN COMPLETED FORM – MUST INCLUDE PROOF OF RESIDENCY AND INCOME VERIFICATION –TO THE WELLESLEY FOOD PANTRY, 207 WASHINGTON ST, WELLESLEY, MA 02481.

Questions? Contact the pantry at 781-235-1188.

Please do not write below this line

Residence verified by ______Proof of income verified by ______

APPROVED by WFP or WHA registrar ______Date: ______