Fresh Bucks Waitlist Application

IMPORTANT NOTE: Our enrollment is currently full. Submitting a Waitlist Application does not enroll you in the program—but it does put you on the waitlist to receive benefits when they are available. *

How many people are in your household, including yourself? *

Monthly household income *

Address *

Date of birth *

Based on your responses, you qualify for Fresh Bucks. Please complete the Fresh Bucks Waitlist Application to indicate your interest in the program. IMPORTANT NOTE: Our enrollment is currently full. *

By checking this box, I am aware that my information is subject to review and verification and that other documentation may be required. I certify that my information is accurate and complete. I agree to provide proof of eligibility if requested and to notify the City of Seattle of any eligibility changes. False or misleading information may result in removal from the program and possible prosecution. I understand that submitting this waitlist application does not guarantee eligibility or enrollment in any programs.
 

Fresh Bucks are a household benefit and enrollment is limited to one per household. I confirm that I am submitting one application for my household and that no one else from my household has applied for or is already enrolled in the Fresh Bucks program
 

The City of Seattle may use the data you provide to research and evaluate outcomes associated with the Fresh Bucks program. The work product of the research will not include identifiable information.
  *

Please enter your first and last name *

Please enter your 10 digit phone number. *

Email address *

Do you receive mail at a different address than your home address? *

What is your age? *

Are there children under the age of 18 in the household? *

What is your race? *

What is your preferred language? *

Please email and mail me the latest Fresh Bucks news and information. *

In general, how would you rate your health? *

Within the past 12 months, I/we worried that food at home would run out before I/we got money to buy more. *

Within the past 12 months, the food I/we bought ran out, and I/we didn’t have money to get more. *

Within the past 12 months, I/we found it hard to buy healthy foods like fresh fruits and vegetables. *

During the past month, how often did you eat fruit? *

During the past month, how often did you eat a green leafy or lettuce salad, with or without other vegetables? *

During the past month, how often did you eat any kind of fried potatoes, including French fries, home fries, or hash brown potatoes? *

During the past month, how often did you eat any other kind of potatoes, such as baked, boiled, mashed potatoes, sweet potatoes, or potato salad? *

During the past month, not including what you just told us about (green salads, potatoes), how often did you eat other vegetables? *