Household Assistance Application

This application is to be completed when client is first applying for assistance and at the beginning of each calendar year while currently receiving assistance. Please note "Certification Period" dates at the bottom of the page.

Contact Information

Total Gross Income:

(The total gross income of ALL household members, before deductions:)
*Farmers and self-employed persons may report net income.) (Amount after expenses)

Does household receive other assistance?

If yes, "check" all types received.

Application Declaration

Applicant to read declaration, date and sign application.

I am a member of the household living at this address provided on this form and am applying on behalf of that household.
All information provided herein, to determine my household's eligibility for emergency aid, is to the best of my knowledge and belief, true and correct.
If applicable, all information provided to or by myself as an authorized representative, is, to the best of my knowledge and belief, true and correct.

Certification Period
In accordance with federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.
To file a complaint of discrimination, write USDA, Director, Office of Adjudication and Compliance, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call 202-260-1026, 1-866-632-9992 (toll free) or 1-202-401-0216 (TDD).
USDA is an equal opportunity provider and employer.
The UTRGV Student Food Pantry. does not discriminate on the basis of race, color, citizenship. religion. gender, national origin, ancestry, age- marital status, disability, sexual orientation including gender identity or expression, unfavorable discharge from military or status as a protected veteran.