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Neighbors Serving Neighbors
Self Certification Form

This form helps us understand how many neighbors are using the pantry and assists us with obtaining grants and funding for the pantry. Thank you for completing it accurately. 

Birthday
Month
Day
Year
Check if anyone in household receives income from following sources
Current living situation
Is anyone in your household currently in the military or a military veteran

Please list the names, birth date, gender, and ethnicity/race of all persons in household:

Date of Birth
Month
Day
Year
Gender
Male
Female
Race/Nationality
Date of Birth
Month
Day
Year
Gender
Male
Female
Race/Nationality
Date of Birth
Month
Day
Year
Gender
Male
Female
Race/Nationality
Date of Birth
Month
Day
Year
Gender
Male
Female
Race/Nationality
Date of Birth
Month
Day
Year
Gender
Male
Female
Race/Nationality
Date of Birth
Month
Day
Year
Gender
Male
Female
Race/Nationality
Date of Birth
Month
Day
Year
Gender
Male
Female
Race/Nationality
Date of Birth
Month
Day
Year
Gender
Male
Female
Race/Nationality
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By signing above , I certify that:

1. I am a member of the above household living at the address provided and I apply for USDA Foods that are distributed through The Emergency Food Assistance Program;

2. All information provided to the agency determining my eligibility is, to the best of my knowledge and belief, true and correct; and

3. If applicable, the information provided by the proxy is, to the best of my knowledge and belief, true and correct. 

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