Food Assistance

Chosen Name*

First Last

Legal Name*

First Last

Pronouns*

Address*

Street Address Address Line 2 City State ZIP Code

What County do you reside in?

Email Address*

Phone Number*

Gender Identity*

Trans Female
Trans Male
Nonbinary
Cisgender Female
Cisgender Male

Nearest Grocery Store*

Acme
Giant
Weis
Wegmans

Ethnicity or Race*

Asian
Black/African American
Caucasian/White
LatinX/Hispanic
Native American
Pacific Islander
Other
Prefer not to say

Age*

Are you currently employed?*

Yes
No

If employed, who is your employer?

How many people reside in your household?*

What is your current monthly household income (for all members of the household)?*

What are the current monthly expenses for the household (for all members of the household)?*

Are you able to provide documentation of your income or expenses if requested (screen shots/documents)*

Yes
No

Are you enrolled in any of the following assistance programs?*

SSI
SSDI
TANF / Welfare
SNAP / Food Stamps
LiHeap / Heating or Utility Assistance
CHIP or Medicaid
Housing Choice Voucher Program
None

How did you learn about this Program?*

If you chose "Other" or "Referred by an Agency" please describe:

Why are you applying for this grant?*

Have you ever applied for a grant from Eastern PA Trans Equity Project in the past?*

Yes
No

If you answered "yes," what type of grant did you apply for?

Please provide information about your background as a transgender person.*

Would you like to receive our monthly newsletter and other updates?

Yes
No

Are you a transgender of nonbinary person or the parent of a transgender person?

Yes
No

I affirm that I am a transgender/gender diverse person or the parent of a transgender child. I furthermore affirm that the information in this application is true and accurate. I agree that any funds or gift cards I receive will be used exclusively for food and sustenance for me or my family*

Click to affirm

Food Assistance Application

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