Little Zion Community Outreach

APPLICATION – DECLARATORY STATEMENT OF ELIGIBILITY

All pre-registering households must complete an Application/Declaratory Statement of Eligibility. An application must be approved and on file in order for the household to receive commodities. This application expires on June 30th every year, but may be extended for an additional, consecutive two years provided the renewal form on the back of the original application is properly completed, approved, and signed by all parties.

Head of Household First Name *

Head of Household Last Name *

Address *

Street Address *

City *

State *

Country *

Postal Code *

Phone *

Email *

Number of Children 0–17 in Household *

Number of Adults in Household *

Number of Seniors 65+ in Household *

Number of Homeless Count *

My household is eligible because (choose ONE): *

Income-Based

SNAP/TANF/SSI

Combined Household Income Amount *

How often do you receive the income entered? *

Are you a resident of the parish you're applying in? *

I certify that I am a resident of the parish listed above.

Is all information true and accurate? *

I certify that the above information is true and correct.

By signing, I agree to the following:

I understand that my household shall only receive donated foods under this application as distributed by this agency.
I understand that I may be prosecuted under current laws for accepting food for which I am not eligible.
I am aware that my application may be selected on a sample basis for verification. Should my application be selected, I will cooperate fully in the verification.
I understand that food received under this program is for my household consumption ONLY.
I certify that I will contact the agency listed above should the gross income or family size of my household change in such a manner that would affect the eligibility of my household.
I understand that I may only receive food from one food pantry.

Signature of Person Filing Application *

Clear

Date *

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Little Zion Community Outreach uses text messaging to provide food distribution updates and community information. Message frequency varies. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. Reply STOP to opt out or HELP for help. Consent to receive text messages is not required to receive services.