• Another Chance of Atlanta, Inc.

    Food Pantry Registration Form

  • Please complete this form in its entirety. Failure to provide all required information may result in your request for assistance being denied.

    Full dates of birth (month, day, and year) are required for all household members. 

    Do not list any other individuals unless you are their parent, legal guardian, or have their explicit permission to include their information on this form.

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  • Date of Birth*
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  • Format: (000) 000-0000.

  • FINANCIAL DATA

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  • Source of Income (please check all that apply)*
  • Marital Status (Please check one)*

  • Family Data

  • List all members of your household. Please provide all the information requested. This data is required by agencies from which we acquire food and other items. 

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  • Do you have children or other adults in your household?*

  • Please Tell Us About Each Member In Your Household

    You MUST include Full Name, Age, Sex and Date of Birth for EACH member
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  • Date*
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  • Georgia Department of Human Services

    THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP) | Household Eligibility Criteria Form
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  • Is the Household Income?*
  • Household Size Monthly Income Weekly Income
    1 $2,610 $602
    2 $3,526 $813
    3 $4,440 $1024
    4 $5,358 $1,236
    5 $6,274 $1,447
    6 $7,190 $1,659
    7 $8,108 $1,871
    8 $9,024 $2,082
    Each additional member $916 $211
  • ***This table shows the monthly and weekly income limit for each family size. If your household income is at or below the income listed for the number of people in your household, you are eligible to receive TEFAP food****
  • Please read: I self-attest that my gross household income is at or below the income listed for the number of people in my household on this form. I self-attest that I live in the area served by The Emergency Food Assistance Program. This form is being completed in connection with the receipt of federal assistance.

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  • Date*
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  • TEFAP 832 Household Eligibility Form
  • Should be Empty: