Seven Loaves Services, Inc. Food Distribution Program Patron Application

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1 Seven Loaves Services, Inc Food Distribution Program Patron Application PLEASE PRINT C L E A R L Y AND PROVIDE A L L THE INFORMATION REQUESTED HOUSEHOLD INFORMATION NAME ' (LAST) TELEPHONE (FIRST) ADDRESS CITY COUNTY STATE ZIP PLEASE LIST A L L THE M E M B E R S OF Y O U R HOUSEHOLD (Including yourself) DATE OF NAMES BIRTH SEX RELATIONSHIP D_ 2) 3) 4) 5) _ 6)?) 8) 9) _! _, _ S U M M A R Y OF HOUSEHOLD DATA NUMBER OF FAMILY MEMBERS 0-5 yrs 6-18 yrs yrs 65+yrs DO Y O U RECEIVE (PLEASE CIRCLE CORRECT RESPONSE) Food Stamps? Yes / No Supplemental Security Income (SSI)? Yes / No Temporary Assistance to Needy Families (TANF)? Yes / No Women and Infant Children's (WIQ Assistance? Yes/No Other assistance? "Yes/No If yes, please specify I UNDERSTAND THAT 1) FALSIFYING INFORMATION ON THIS APPLICATION M A Y M A K E M E INELIGIBLE TO RECEIVE SERVICES PROVIDED B Y SLS 2) INAPPROPRIATE BEHAVIOR AND PROFANE COMMENTS M A Y ALSO RESULT IN SUSPENSION OR TERMINATION OF SERVICE 3) UNDER NO CIRCUMSTANCES WILL SLS SERVE ANYONE WHO IS INTOXICATED OR UNDER THE INFLUENCE OF ILLEGAL DRUGS AND 4) I CAN RECEIVE A N SLS FOOD DISTRIBUTION ONLY ONCE A WEEK AND A USDA FOOD DISTRIBUTION O N L Y ONCE A MONTH FROM A SINGLE SOURCE I CERTIFY THAT THE INFORMATION I H A V E PROVIDED ON THIS APPLICATION IS TRUE TO THE BEST OF M Y ABILITY SIGNED DATE

2 FOOD RECEIVED PER VISIT Note Please ask patron if any of the data on his/her application has changed Date Weight Date Weight Date Weight SPECIAL EVENTS (VOLUNTEERS CIRCLE AND/OR COMMENT'AS APPROPRIATE WHEN RECEIVED) EASTER BASKETS - YES / NO - IF YES, N U M B E R OF CHILDREN SCHOOL SUPPLIES - YES / NO -IF YES, N U M B E R OF CHILDREN THANKSGIVINQ TURKEY,-,YES / NO CHRISTMAS TURKEY - YES NO ' ' - / - CHRISTMAS G I F T S - Y E S / N O - I F YES, N U M B E R OF CHILpREN ' ' ' COMMENTS ^

3 Seven Loaves Services, Inc Programa de Distribution de Alimentos NOMBRE TELEFONO DIRECCION CIUDAD PAIS ESTADO NOMBRE ZIP NACIMIENTO SEXO PARENTESCO 1) 3) 4), 6) ' 8) ' 9) NUMERO DE MIEMBROS DE LA FAMILIA 0-5anos 6-18 aros afios 65+anos USTED RECIVIO ( POR FAVOR REDONDEE LA RESPUESTA CORRECTA )CUPONES PARA ALIMENTOS? Si /No Supplemental Security Income (SSI)? Si / No Temporero Asistencia para Needy Family (TANF)? Si / No Women and Infant Children's (WIC) Otras Asistencias? Si / No Si contest que Si, especifique Asistencia? Si / No ENTIENDO QUE 1) FALCIFICANDO LA INFORMACION DE ESTA APLICACION PODRIA HACERINELEGIBLE PARA LOS SERViCIOS PROVISTOS POR SLS 2) CONDUCTAINAPROPIADA 0 COMENTARIOS MALINTENCIONADOS, TAMBIEN PODRIA RESULTAR EN LA SUSPENCION 0 CANCELACION DEL SERVICIO 3) BAJO NINGUNA CIRCUNSTANCIA SLS PROVEERASERVIO A NADIE QUE ESTE BAJO LOS EFECTOS DE ALGUNA DROGAILEGAL AND 4) SOLO PODRE RECIVIR UNA DISTRIBUCION DE COMIDA DE SLS A LA SEMANA Y UNASOLA DISTRIBUCION AL MES DE LA USDA DE UNA SOLA FUENTE YO CIRTIFICO QUE LA INFORMACION QUE ACABO DE PROVEER EN ESTA APLICACION ES CIERTA A Ml MAYOR ENTENDER SIGNED DATE

4 FOOD RECEIVED PER VISIT Date Weight Date Weight Date Weight SPECIAL EVENTS (VOLUNTEERS CIRCLE AND/OR COMMENT AS APPROPRIATE WHEN RECEIVED) EASTER BASKETS - YES / NO - IF YES, NUMBER OF CHILDREN SCHOOL SUPPLIES - YES / NO - IF YES, NUMBER OF CHILDREN THANKSGIVING TURKEY - YES / NO CHRISTMAS TURKEY - YES / NO CHRISTMAS GIFTS - YES / NO - IF YES, NUMBER OF CHILDREN COMMENTS

5 SELF-DECLARATION OF INCOME Agency Number Agency Name Name of Worker _ Revised Income Level Effective Dates July 1* Jane 30,2013 J tate of Virginia - USDA The Emergency Food Assistance Program (TEFAP) Applicant's Name Phone # Address Apartment # City State Seven Loaves Services, Inc Zip Does Applicant's entire household receive any of the following? SNAP (Food Stamps) ()Y ()N Supplemental Security Income (SSI) ( ) Y ( ) N Temporary Assistance for Needy Families (TANF) () Y () N Is the Applicant a one-person household receiving Medicaid? ( ) Y ( ) N If yes to any of the questions above, Applicant is automatically qualified for TEFAP and you should list ONLY names, ages, and genders in the grid below If no to all questions above, complete the entire grid Names Age M/F Total Annual Income I certify that I am the only person in the household at the above address who applied for this assistance I certify that the income of all the persons in my household is not more than the amount shown and the information I have provided is correct to the best of my knowledge I understand that I may only receive TEFAP food once a month STATEMENT OF NON-DISCRIMINATION In accordance with Federal law and US 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 alleging discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, DC or call toll free (866) (voice) Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay at (800) or (800) (Spanish) USDA is an equal opportunity provider and employer Applicant's Signature Date Applicant's Signature, Date Applicant's Signature, Date Applicant's Signature, Date Applicant's Signature, Date Applicant's Signature Date

6 ALTERNATE An alternate or proxy can be named to pick up food for the applicant The applicant must come in a minimum ' of once in a six-month period to fill out a self-declaration form An alternate or proxy may not pick up food for the applicant if there are any changes to the household size or the total income Only if the alternate can verify the correct information, can food be picked up Applicant's Name, Alternate's Name Applicant's Signature Date **Food Bank partner agencies - please note! Self-Declaration forms must be turned into the Food Bank at the end of December and the end of June The same form can be used for the same client (unless information changes) from January through June and from July through December, All clients receiving USDA food must be recertified (new forms filled out) in January and July!

7 Agency Name Agency Worker?)eclaraci6n de ingresos Nombre del solicitante Direccion Ciudad Telefono # Apartamento# Codiso Postal Estado ^El solicitante debe contestar si recibe alguna de las siguientes ayudas? Asistencia temporal para familias necesitadas (TANF] f ] si ( ] no SNAP festampillas de comida] f 1 si f 1 no EI solicitante vive con una persona que recibe Medicaid ( ) si ( }no Recibe dinero adicional f ) si f 1 no Si usted contesto, SI en alguna de las preguntas anteriores, usted automaticamente califica para TEFAP El solicitante debe Uenar el cuadro con la siguiente informacion el nombre, la edad, el sexo del individuo Nombre 1,0 _ pil total del ingreso anual edad M/F Entradas Mensual Semanal Cada2 semanas Anual Certifico que yo soy la linica persona en este hogar y que vivo en esta direccion por la cual estoy solicitando aynda Tambien certifico que la informacion proporcionada de los ingresos de las personas que viven eonmigo es correcta y verdadera Yo entiendo que solamente puedo recibir ayuda alimenticia una al mes Declaration de discrimination De acuerdo con la Ley Federal y la Politica del Departamento de Agricultura, esta institucion tiene prohibido la discriminacion por motivos de raza, color, origen, sexo, edad o incapacidad Si tiene una queja de discriminacion, escriba a USDA, Director Office of Adjudication, 1400 Independence Avenue, SW, Washington, DC o Uame al numero gratuito (866) (voz) Individuos que tengan incapacidad auditiva o del habla pueden comunicarse con USDA a traves del Federal Relay al (800) o (800) (Espafiol) USDA es un empleador que provee una igual oportunidad Firma del solicitante fecha, Firma del solicitante fecha Firma del solicitante,, fecha, Firma del solicitante fecha Firma del solicitante fecha, Firma del solicitante fecha

8 Un representante puede ser nombrado para recoger la ayuda alimenticia El solicitante puede venir mfni una vez cada seis meses y llenar la solicitud de ayuda El representante del solicitador no podra venir a recoger la ayuda alimenticia si hay cambios en el hogar o del ingreso Solamente si el representante del solicitante puede verificar la informacion podra recoger la ayuda alimenticia Nombre del solicitante Nombre del representante Firma del solicitante fecha ** Las agendas del banco de alimentos deben hacer una declaration de las aplicaciones recibidas y deberan ser entregadas al Banco de Alimentos al final de los meses de diciembrey junio La misma aplicacion del solicitante puede ser utilizada siempre y cuando su informacion no haya cambiado Todos los clientes que reciben ayuda alimenticia deben ser recertificados y nuevas aplicaciones deben ser hechas en los meses de enero y Julio

9 Seven Loaves Driver Questionnaire Name of Driver (Please Print) Does your personal vehicle (ie, the vehicle used when assisting Seven Loaves Services, Inc) insurance coverage meet or exceed the minimum coverage of 100,000 (bodily injury each person) 300,000 (bodily injury each accident) and 100,000 (property damage each accident) Please circle the appropriate response No If you answered "No" to the above question, are you willing to raise your coverage to the specified minimums? Please circle the appropriate response Yes Yes No Do you agree not to transport children in the course of driving for Seven Loaves? Please circle the appropriate response Yes No Comments and/or recommendations pertaining to the above questions or any other aspect of your support to Seven Loaves Please sign and date this questionnaire and, return it to the food pantry in the envelope provided before you start driving Thank you for your cooperation and assistance (Signature) (Date)

10 SEVEN LOAVE S SERVICES, INC Volunteer Information Form Name Street Address Mailing Address (if different) Primary Phone Alternate Phone (eg, cell and/or work) Address Fax Language(s) (other than English) Emergency Contact Information Name Address Phone Alternate Phone (eg, cell and/or work) Address Relationship Volunteer interests (eg, food pickup or distribution, clerical, special projects, etc - see our informational sheet for more examples, or offer new ideas and talents)

11 SEVEN LOAVES SERVICES, INC Volunteer Information Seven Loaves serves food to those in need Our volunteers do splendid things with limited resources We are eager for others to join the volunteers whose time, energy and ideas help Seven Loaves in pursuing its mission We obtain food (and occasionally other items) from a variety of sources for periodic distribution to our patrons A large part of our volunteer efforts involves picking up food from grocery stores, warehouses, farmers' markets, etc, and distribution of this food from our pantry located in the rear basement of the Middleburg United Methodist Church at 15 West Washington Street, Middleburg, Va We also maintain a clothes closet at the same location Our normal distribution hours are 10 am-noon on Monday, Wednesday and Friday Volunteer Needs 1 Food and Clothes Distribution Regular and substitute volunteers are always needed Monday, Wednesday and Friday mornings to help distribute food and clothes to our patrons Time commitment is typically about four hours ( ) We also have a special distribution of USDA commodities on the same days one week a month, typically in the middle of the month Our clothes closet is open during pantry hours and volunteers are also needed to staff this part of our mission 2 Transportation We receive food donations from several supermarkets in the Middleburg - South Riding - Marshall areas and on the days we are open for distribution, we need regular and substitute volunteers to pick up food at approximately 9 am and deliver it to the pantry We also need drivers to collect the bulk lots of food we order from the Blue Ridge Area Food Bank in Winchester, V A every Thursday morning Finally, on a seasonal basis, we pick up fresh produce from Farmers' Markets in Warrenton, The Plains and some other locations A vehicle with large storage capacity is needed for each of these types of pick-ups, but a heavy duty vehicle is required for the Winchester pick-ups 3 Pantry Management We have a small storeroom where we house the bulk of our inventory Regular and substitute volunteers are needed on Thursdays to unload the truck(s) from Winchester, and otherwise to restock the pantry throughout the week This process also includes monitoring inventory levels and assisting in ordering food supplies 4 Clerical Support We have on-going correspondence, forms, filing and special mailings for which clerical support is desired on a periodic basis 1

12 5 Technology We are in the process of re-creating a web-site Individuals experienced in web site development and administration are needed to assist in the creative and technical aspects of formation, as well as on-going maintenance In addition, presently most of our activities and records are paper-based, including our day-to-day interactions with patrons, but we hope to migrate to a more efficient computer-based system Volunteers experienced in information technology who can design, develop and implement systems to automate our patron intake, inventory and pantry operations would be appreciated 6 Food Drives We participate in several major food drives each year sponsored and conducted by other organizations for our benefit We need volunteers to interact with these sponsors, plan and coordinate the drives, and process and store the food received 7 Special Projects As a complement to our food distribution, we provide Easter baskets, school supplies, Thanksgiving turkeys and Christmas gifts on a seasonal basis, typically in concert with one or more churches in the Middleburg area We need volunteers to plan, organize and administer these initiatives 8 Publicity and Public Relations We hope to expand our community outreach by creating and circulating brochures, a periodic newsletter, articles for local media and content for our website Volunteers with good writing and communication skills are desired to assist in this effort 9 Accounting and Finance Volunteers with financial, accounting, budgeting, investment and analytic skills are needed to assist with financial management services, including periodic statement preparation and internal and external reporting 10 Volunteer Recruitment and Coordination As an all-volunteer organization, we rely on the generosity of many volunteers who donate their time and energy to our mission As such, we are constantly in need of people to help out on a one-time and continuing basis To that end, we could use the help of volunteers to recruit and coordinate the activities of all our volunteers 11 Facility Cleaning, Maintenance and Repair Our facility includes large commercial refrigerators and freezers and receives significant foot traffic each week moreover, as a food distribution facility, adherence to a high standard of cleanliness is important Volunteers interested in performing periodic cleaning and maintenance are welcome 12 Other As with any organization or activity, unexpected needs arise from time to time and volunteers are needed to assist "in whatever it takes" Perhaps more importantly, we need new ideas for things we could and should be doing and welcome suggestions for other projects For further information, or to volunteer, please call Melanie Maloney at our office, (540) or at (540)

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