Here to Help In Your Time of Need

Here to help you

Here to Help

The Utica Food Pantry is here to help you in your time of need. We provide food to supplement your main grocery sources.

We will assess your needs to determine if there are other resources that could provide additional assistance.

The Utica Food Pantry is here to help you in your time of need. We provide food to supplement your main grocery sources.

To become eligible, you must bring proof of residency. Acceptable proof of residency includes a recent utility bill, sewer/water bill, etc.

Once eligibility is determined, we will assess your needs to determine if there are other resources that could provide additional assistance.

Intake Form

"*" indicates required fields

Please take a moment to answer all questions so that we may serve you better. We are required to obtain the following information from our clients for funding and reporting purposes; however, we will serve anyone in need regardless of ethnicity, race, color, national origin, sex, age, disability or political beliefs. This information is confidential and will not have a negative effect on services provided to you. NOTE: you will need proof of identity for all members of your household in order to complete this form. Proof of identity includes: driver’s license, photo ID card, permanent resident card, birth certificate, military ID, immigration documents, citizenship or naturalization certificate. Social Security cards are not an acceptable form of identification.

Client Documentation

New Client*

Yes

Existing Client*

Yes

Today's Date*

Name*

First Name Last Name

Type(s) of ID

Driver’s License

Birth Certificate

Citizenship or Naturalization Certificate

Photo ID Card

Military ID

Permanent Resident Card

Immigration (USCIS) Documents

*Social Security Cards are not an acceptable form of identification.

Address*

Street Address Address Line 2 City State ZIP Code

Type of address verification*

Phone, cable or utility bill

Any U.S mail with the applicant’s name and street address postmarked dated within 30 days of application.

Email*

Phone*

Household Information

Total number of individuals living in your household*

Total number of adults ages 18 to 55 in your household*

Total number of seniors over age 55 in your household*

Total number of children under age 18 in your household*

Applicant Signature*

Date*

How would you best describe your employment status?*

Employed

Unemployed

Retired

Disabled

Student

Check all that apply

Is this your first time receiving food this year?*

Yes

What is your estimated total monthly income?*

Demographic Information

Which best describes your household?*

Single parent, HOH (female)

Single parent, HOH (male)

2+ adults with children

2 parent family

single adult(s)

Married (no children)

How would you best describe yourself?

African American

Asian American

Hispanic

Caucasian/White

Native American

Other

This section is optional and used solely for funding purposes, it will not affect services you receive today.

General Questionnaire

Are you homeless?*

Yes

Are you disabled?*

Yes

Please check all public benefit programs you are currently participating in*

Would you like more information about any of these public benefit programs?*

Yes

Dietary Needs

Does anyone in your household have any special dietary needs, such as:*

Food Allergies – Please Specify*

Other – Please Specify*

Household Information

Head of Household*

First Name Last Name

Date of Birth*

Proof of Identity*

Max. file size: 2 MB.