THANKSGIVINGFOOD BOX DISTRIBUTION - POLK COUNTY APPLICATION

In order to be considered for a free Thanksgiving food box, applications must be completely filled out. Assistance is at the discretion of Lighthouse Ministries, Inc., and completion of this application does not guarantee acceptance.

If you are applying for assistance from other organizations, your application will be denied.

Those approved for food boxes will be notified by mail no later than November 19, 2010. You may also call (863)687-4076 to receive confirmation from a staff member.

Applications must be hand-delivered to 117 E. Magnolia St. (Lighthouse Ministries Men’s Center) by 5:00 p.m. on NOVEMBER 12, 2010.

p Proof of income (including all outside assistance, food stamps, etc.)p Proof of all expenses (including utilities, insurance, rent, medical bills, etc.)Without this information, we cannot process your application, and your aid will be denied. Applications will be available November 1 - 12. Late applications will not be accepted.

p Valid Photo Identificationp Social Security Cards for all applying in the householdYou will be unable to claim your food box without these items. Distribution will take place at the Light-house MInistries Men’s Center (117 E. Magnolia St.)

All applicants are required to provide copies of the following items with their application (due no later than 5:00 p.m. on November 12, 2010):

All applicants are required to provide the following items on the day of distribution (Tuesday, November 23, 2010 from 9 am - 2 pm):

Today’s Date: ________________________________________

Name: ______________________________________________ ____________________________________________________ _ First MI Last

Date of Birth:__________________________________________ Social Security No.: ___________________________________

Race (Optional): p American Indian/Alaskan Native p Native Hawaiian/Pacific Islander Marital Status: p Married p Separated p African American p Caucasian p Hispanic p Asian p Other p Divorced p Widowed p Single

P.O. Box: ___________________________________________________ City: _______________ State: ______ Zip: __________

Street: ____________________________________________________ City: _______________ State: ______ Zip: __________

Home Phone: (_____) ________________ Cell Phone: (_____) _____________________ Email: ____________________________

Spouse’s Name (optional): ___________________________________________________________________________________ First MI Last

Date of Birth:__________________________________________ Social Security No.: ___________________________________

Race (Optional): p American Indian/Alaskan Native p Native Hawaiian/Pacific Islander p African American p Caucasian p Hispanic p Asian p Other

Children in Household: Total Amount of People in Household: _____________

1. Name: ____________________________________ SS#: ________________________ Birthdate: _____________________

2. Name: ____________________________________ SS#: ________________________ Birthdate: _____________________

3. Name: ____________________________________ SS#: ________________________ Birthdate: _____________________

4. Name: ____________________________________ SS#: ________________________ Birthdate: _____________________

5. Name: ____________________________________ SS#: ________________________ Birthdate: _____________________

6. Name: ____________________________________ SS#: ________________________ Birthdate: _____________________

The love of God is expressed through the outreach of Lighthouse Ministries. It is our prayer that through this ministry, you would come to know the One who knows and loves you.

Have you come to a place in your spiritual life that you know for sure that if you died today you would go to heaven? p Yes p No

Suppose you were to die today, and, as you stand before God, He asks you, “Why should I let you into my heaven?” What would you say? ____________________________________________________________________________________________________________________

Are you a member of a local church? p Yes p No Church Name: _________________________ Pastor: ______________________________

Additional Information Required on Back ---->

THANKSGIVING“SEE THE NEED, HELP US FEED” POLK COUNTY APPLICATION

117 E. Magnolia St.| Lakeland, FL | www.lighthousemin.org | (863)687-3705Applications are available November 1-12, and must be completely filled out to be considered.

AUTHORIZATION FOR RELEASE OF INFORMATIONI authorize Lighthouse Ministries, Inc. and its staff to release and/or request information which is necessary for the approval or denial of my application. In addition, I authorize Lighthouse Ministries, Inc. to contact and share information with other agencies who may be able to assist me with my needs. I understand that this consent can be revoked by me at any time prior to action being taken on my behalf in the processing of this application. Revocation of consent must be in writing. This action will auto-matically withdraw my application, and I may be terminated as a client of Lighthouse Ministries, Inc. I certify that all information provided by me is true, and I forfeit consideration for assistance if found to be false or incorrect. The above information is true and accurate to the best of my knowledge and belief. I understand that false information could lead to denial of services and/or legal prosecution.

Applicant’s Signature: ____________________________________________ Date: ____________________________________

REMINDER: Assistance is at the discretion of Lighthouse Ministries, Inc. Completion of application does not guarantee acceptance. All applications must be hand-delivered to 117 E. Magnolia St. (Lighthouse Ministries Men’s Center) no later than 5:00 p.m. on November 12, 2010. Food box distribution will take

place on Tuesday, November 23, 2010 from 9:00 am - 2:00 p.m at 117 E. Magnolia St. (Lighthouse Ministries Men’s Center).

RECEIPT (to be signed at time of food box pick-up)The undersigned recipient understands that any items being given away by Lighthouse Ministries, Inc. were all received by Light-house as donations from reputable entities. However, Lighthouse cannot be responsible for the condition of said donated items. Accordingly, the undersigned hereby indemnifies and holds harmless Lighthouse Ministries, Inc. against any and all claims, li-abilities, losses, damages, expenses, or lawsuits directly or indirectly arising from or in any way connected with the donated items received today from Lighthouse Ministries, Inc.

Recipient’s Signature ____________________________________________ Date: ____________________________________

p Approved p Denied - Reason: __________________________________________________________________________

APPLICATION WILL NOT BE CONSIDERED UNLESS FULLY COMPLETED. Revised: 10/25/2010 (LMI/EG)

SOURCES OF INCOME: AMOUNT:

Employment: $

SSI: $

TANF (A.F.D.C.): $

Veterans: $

Child Support: $

Pension: $

Food Stamps: $

Total Income: $

Receiving Section 8 Housing? p Yes p No

Receiving Section 8 Utility Assistance? p Yes p No

Identification: __________________________________

SOURCES OF EXPENSE: AMOUNT:

Rent: $

Utilities: $

Fuel: $

Phone: $

Credit Cards: $

Cable: $

Furniture: $

Medical Bills: $

Child Support: $

Car Payment: $

Car Insurance: $

Food/Water: $

Total Expenses: $