Household Application for Food: This Application is to be completed by a household member. 

By signing in the box, I certify that:

I am a member of the household currently living at the address provided in application and that, on behalf of the household, I am applying for food assistance.

All information provided to the agency determining my Household's eligibility is, to the best of my knowledge and belief,  true and correct.

The information provided by the household's "Authorized Representative" (as named below) is also, to the best of my knowledge true and correct.