COVID-19 Food Assistance Form

This is a food assistance program ONLY.

If any other financial assistance is needed, limited funds are available.

This is made possible by the generous donations of the Muslim community.

Name: *

Email Address: *

Application Date: * +

Phone: *

Language Spoken: *

Address: *

City: *

State: *

Zip Code: *

Marital Status

Marital Status: *

# of Children: *

Name of Spouse: *

Spouse Phone: *

Employment Status: *

Employed

Unemployed

Did you lose your job as a result of the COVID-19 closure? *

Yes

Current/Former Place of Employment: *

Do you receive food assistance from other sources? *

Yes

Is there any other information you would like to provide?

Preferred store for using a voucher: *

Signature of Applicant: *

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