APPLICATION

CITY OF BALDWIN PARK

FOOD VOUCHER PROGRAM

This program is supported by Community Development Block Grant Coronavirus (CDBG-CV) funds from the Federal Department of Housing and Urban Development (HUD). Federal regulations require that we obtain the following information to document that assistance is being provided to low and moderate-income households. This information is collected for statistical purposes only and will be kept confidential. The Participant/Guardian should complete this form indicating all persons residing within their household, regardless of whether or not they are related. Income verification is mandatory for program participation. You will also be required to provide photo identification at the food distribution site when you pick up your food.

You have three options to bring in proof of unemployment or your household income (payment stubs, tax returns, unemployment checks, proof of social security or disability income, school lunch program eligibility form, or other applicable information). You can provide any of these documents by sending them in the following three ways:

  1. Via email to This email address is being protected from spambots. You need JavaScript enabled to view it.
  2. Via mail to: City of Baldwin Park, attention Carol Averell - Housing Division (14403 E. Pacific Avenue, Baldwin Park, CA 91706)
  3. Bring to Grocery Outlet when food is picked up (as instructed by city staff)

 

Please let us know your name.

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Please let us know your email address.

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INCOME is defined as the total annual gross income of all family and non-family members 18+ years old living within the household. All sources of income must be counted from all persons in the household based on anticipated income expected within the next 12 months.

 

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Please list anyone in your household that is participating in this program. This may be adults or children. Only list household members who are participating in the program.

Participant 1

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Participant 2

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Participant 3

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Participant 4

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Participant 5

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That the information provided on this form is accurate and complete to the best of my knowledge, and that I am a resident of the City of Baldwin Park. I further acknowledge that eligibility for services funded through the CDBG-CV program is based upon having a qualifying annual family income level or belonging to a group that is presumed to be low- or moderate-income, and that the income level and/or status I have indicated in this self-certification may be subject to further verification by the agency providing services, the City of Baldwin Park and/or HUD.

 

Applicant(s) acknowledge that personal and financial information may be subject to public disclosure under the California Public Records Act. If chosen for funding, applicant will be required to provide financial documentation, including but not limited to tax returns, paystubs, EDD information, letter from employer stating reduction of hours or job loss, and/or other applicable documentation.