USDA Program Eligibility Questionnaire Form
Answer the following questions to help determine your potential eligibility for USDA-related programs.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
State of Residence
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other / U.S. Territory
Do you currently live in a rural area as defined by USDA?
*
Yes
No
Not Sure
Household Size (number of people living in your home)
*
Estimated Annual Household Income (before taxes)
*
Please Select
Less than $20,000
$20,000 - $34,999
$35,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 or more
Prefer not to say
Are you a U.S. citizen or permanent resident?
*
Yes
No
Are you currently receiving assistance from any government programs?
SNAP (Supplemental Nutrition Assistance Program)
WIC (Women, Infants, and Children)
Medicaid
TANF (Temporary Assistance for Needy Families)
None of the above
Other
Please briefly describe your interest or need for USDA programs.
Check Eligibility
Should be Empty: