This information is confidential and will not affect your eligibility for food. Every question must be answered clearly (N/A, none, or 0 if your answer does not apply).
Mitzvah Food Program Recipient Intake Form

Contact Information

Click here for a list of food pantry locations and schedules.
This is a mandatory field if you answered that you do need delivery. For example: You are home-bound, or because your work schedule makes it impossible for you to come to the pantry during the hours that it is open. Please note that it may take time to place you on a delivery route as we depend on volunteers to deliver to you.
Do you have a dog or cat? *

Dietary Information

Kosher designates food that satisfies the requirements of Jewish law. This means, in short, that no meat and dairy can be consumed together, no shellfish (including lobster and shrimp), and no pork may be eaten. Also, in order to be kosher, kosher animals must be butchered in a specific way that satisfies the requirements of Jewish law.

Household Income Information

Household Benefit Information

Person 1 (You)

Please fill out the information below for every person in your household including yourself
Do you identify yourself as Lesbian, Gay, Bi-sexual, Transgender, Queer or Questioning?
Gender *

Person 2

Do you identify yourself as Lesbian, Gay, Bi-sexual, Transgender, Queer or Questioning?
Gender *

Person 3

Please fill out the information below for every person in your household including yourself
Do you identify yourself as Lesbian, Gay, Bi-sexual, Transgender, Queer or Questioning?
Gender *

Person 4

Please fill out the information below for every person in your household including yourself
Do you identify yourself as Lesbian, Gay, Bi-sexual, Transgender, Queer or Questioning?
Gender *

Person 5

Please fill out the information below for every person in your household including yourself
Do you identify yourself as Lesbian, Gay, Bi-sexual, Transgender, Queer or Questioning?
Gender *
If there are more than 5 members of your household, please list them with all there pertinent information here.

U.S. Household Food Security Survey Module:

Six-Item Short Form Economic Research Service, USDA -- These next questions are about the food eaten in your household in the last 12 months and whether you were able to afford the food you need.
1. “The food that (I/we) bought just didn’t last, and (I/we) didn’t have money to get more.” Was that often, sometimes, or never true for (you/your household) in the last 12 months? *
2. “(I/we) couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for (you/your household) in the last 12 months? *
3. In the last 12 months, did (you/you or other adults in your household) ever cut the size of your meals or skip meals because there wasn't enough money for food? *
4. [IF YES ABOVE] How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months?
5. In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food? *
6. In the last 12 months, were you ever hungry but didn't eat because there wasn't enough money for food? *