| Name of Person making application: |
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| Your Phone Number: |
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| Your Relationship to the Applicant: |
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| Name of Applicant: |
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| Address: |
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| CityZip |
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| Phone: |
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| Date of Birth: |
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| Gender: |
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| Race: |
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| Ethnicity: |
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| Primary Language Spoken: |
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| Marital Status: |
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| Living Situation: |
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| Is there a Caregiver in the household? |
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| Does Applicant need outside assistance evacuating in case of a hurricane? |
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| Are they registered with Broward County Special Needs registry? |
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| Individual Monthly Income: |
Do Not Wish To Answer |
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| Couples Monthly Income: |
Do Not Wish To Answer |
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| Is the applicant receiving food stamps? |
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| Estimated Total Individual Assets: |
Do Not Wish To Answer |
| Estimated Total Couple Assets: |
Do Not Wish To Answer |
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| Is this person aware of the referral? |
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| Does this person have enough money to buy the food they need? |
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| Are they able to handle preparing frozen meals? |
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| How have they been managing until today? |
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| Who currently does their food shopping? |
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