Northampton Survival Center | Annual Re-Registration Form

Step 1 of 3 - Household Information

APPLICANT INFORMATION

Name(Required)

First Last

Street Address(Required)

City(Required)

Used for monthly newsletter, occasional communication, and online ordering

Phone(Required)

Date of Birth(Required)

Month

Day

Year

Gender(Required)

Race (check all that apply)(Required)

Black/African American

White/Caucasian

Asian

Mixed Race

Native American

Other

Latino/a/x?(Required)

Yes

Number of people in household(Required)

Language(s) spoken at home(Required)

Houseless?(Required)

Yes

Subscribe to texts for pantry updates?(Required)

Yes

OTHER HOUSEHOLD MEMBERS

Additional Household Member #1

Name(Required)

Date of Birth(Required)

Month

Day

Year

Gender(Required)

Relationship to head of household(Required)

Race (check all that apply)(Required)

Black/African American

White/Caucasian

Asian

Mixed Race

Native American

Other

Other(Required)

Latino/a/x?(Required)

Yes

Additional Household Member #2

Name(Required)

Date of Birth(Required)

Month

Day

Year

Gender(Required)

Relationship to head of household(Required)

Race (check all that apply)(Required)

Black/African American

White/Caucasian

Asian

Mixed Race

Native American

Other

Other(Required)

Latino/a/x?(Required)

Yes

Additional Household Member #3

Name(Required)

Date of Birth(Required)

Month

Day

Year

Gender(Required)

Relationship to head of household(Required)

Race (check all that apply)(Required)

Black/African American

White/Caucasian

Asian

Mixed Race

Native American

Other

Other(Required)

Latino/a/x?(Required)

Yes

Additional Household Member #4

Name(Required)

Date of Birth(Required)

Month

Day

Year

Gender(Required)

Relationship to head of household(Required)

Race (check all that apply)(Required)

Black/African American

White/Caucasian

Asian

Mixed Race

Native American

Other

Other(Required)

Latino/a/x?(Required)

Yes

Note: If you have more than five people in your household, a staff member will reach out to you to get their information.

INCOME

Total Monthly Household Income(Required)

Include monthly income for all household members before any deductions or taxes.

SNAP/food stamps (per month)(Required)

If you don't receive SNAP just put 0

Types of income for the household (check all that apply)(Required)

SSI

SSDI

Social Security

Child Support

Cash Assistance

Veteran's benefits

Work

Unemployment

Other

Other(Required)

USDA/TEFAP DECLARATION OF ELIGIBILITY

Declaration of financial need is sufficient to receive USDA/TEFAP foods on a guest's first visit. Subsequent visits require a declaration of eligibility according to the guidelines below. Guests must be allowed to self-declare eligibility. Verification of residence, income, or receipt of benefits is not required. Photo ID and Social Security numbers are not required, and requesting this information is prohibited by USDA and the Commonwealth of Massachusetts. Declaration of Eligibility must be kept on file for each guest for the current fiscal year plus three previous years. Programs must track each time guests receive USDA, but the guest is not required to sign or recertify eligibility after initial declaration. Participants are required to recertify eligibility annually.

Do you receive any of the following types of assistance? (check all that apply)(Required)

WIC

TANF

SSI

Fuel Assistance

SNAP

Veteran's Aid

Head Start

AFDC

Medicaid (MassHealth)

Free/Reduced-Price School Lunch

EAEDC

I do not receive any of these types of assistance

If you do NOT receive any of these benefits, is your household income at or below the following income guidelines?(Required)

YES

# of Household Members	Annual Income	Monthly Income	Weekly Income
1	37,650	3,138	724
2	51,100	4,258	983
3	64,550	5,379	1,241
4	78,000	6,500	1,500
5	91,450	7,621	1,759
6	104,900	8,742	2,017
7	118,350	9,863	2,276
8	131,800	10,983	2,535
For each additional household member, add:	+13,450	+1,121	+259

*TEFAP Income Guidelines 2024-2025

If you do NOT receive any of the above benefits OR meet income guidelines, you may declare financial need to receive USDA/TEFAP foods on your first visit ONLY. Eligibility according to the above requirements must be certified at subsequent visits.

Check HERE to declare financial need(Required)

YES

Consent(Required)

I hereby certify that all information submitted is true and accurate to the best of my knowledge and belief.

Today's Date(Required)

Signature(Required)

This institution is an equal opportunity provider and employer.

Select Language:

APPLICANT INFORMATION

OTHER HOUSEHOLD MEMBERS

Additional Household Member #1

Additional Household Member #2

Additional Household Member #3

Additional Household Member #4

INCOME

USDA/TEFAP DECLARATION OF ELIGIBILITY