Mobile Intake Form

Mobile Food Pantry Sign Up Sheet

Household Size	Monthly Income Maximum
1	$1,815
2	$2,452
3	$3,090
4	$3,725
Each Additional Member	+$ 638

Which mobile will you attend?

Name
Address
City, State, Zip
E-mail
# of children (under 18) in household
# of senior (65 and older) in household
# of adults (18 - 64) in household
I certify that I meet the Income Guidelines as outlined and am in need of food assistance.
Name:
Enter Security Code:

Any questions? Call us at 701-232-6219 or email mobileintake@lssnd.org

Our Affiliations

1720 3rd Ave N. | Fargo, ND 58102 | 701.232.6219
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