Temporary Unemployment Nutrition Aid Form
Applicant Information
First Name
Last Name
Date of Birth
SSN (Last 4 Digits)
Phone Number
Email Address
Current Address
Unemployment Details
Date Unemployment Began
Reason for Unemployment
Laid Off
Furlough
Reduced Hours
Other
Details (if Other)
Household Information
Household Size
Dependents (Names, Ages, Relationship)
Income and Benefits
Current Household Monthly Income
Other Assistance (SNAP, WIC, etc.)
Additional Comments