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2. City of Middletown Double Dollars Registration Form
   Market shoppers eligible for food benefits (WIC/SNAP/Senior Vouchers) can receive a dollar-for-dollar match for purchasing fresh produce, up to $40 per month. SNAP recipients can buy market tickets with their EBT Card to purchase fruit, vegetables, dairy, eggs, and baked goods. To be eligible for the program, one must be registered for WIC/SNAP or have a Senior Voucher and fall below the income threshold. See chart below to determine if you qualify.
4. PERSONAL INFORMATION
6. Name
7. Email Address
9. Address
11. City
12. State
13. Zip Code
15. Phone Number
16. Cell Number
18. Number of People in Household*
    -- Select One --12345678

    Select the number of people living at your place of residence.
19. Total Household Income*
    Total income generated by all those living in your residence.
21. What is the best way to contact you?*
    -- Select One --Phone CallEmailMail

    Select the best way to send you information.
23. INCOME VERIFICATION INFORMATION
    The Double Dollars program is funded through a HUD Community Development Block Grant. In order to eligible for the benefit, the City of Middletown needs to verify income levels for those who participate.
25. Verification Information
    Applicants need to submit information showing eligibility based on income. Please attached any of the following in order for the City to verify income status: Please provide your Client ID for SNAP and voucher number for FMNP. These can be found on your FMNP voucher or SNAP card.
27. SNAP Number
    Your SNAP number consists of the following: "Issuer, Client ID, SUF and CD" (See image below)
28. FMNP VOUCHER #
30. 
31. CDBG Demographic Information*

    1. White
    2. African American
    3. Asian
    4. African American & White
    5. Multi-Racial
    6. Hispanic

    Please select how you identify.
33. SIGNATURE
    Due to Covid-19, electronic signatures are being accepted. Please type your full name and date the form prior to submission. This will qualify as an electronic signature.
35. NAME*
36. DATE*
    DATE
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit Submit and Print

* indicates a required field