C3 – College Community Connection Application and Contract for Your Bargain Grocer Food Vouchers

Eligibility for C3/Your Bargain Grocer Food Voucher:

• Full time student
• PELL/TAP grant eligible and/or
• Documented exigent circumstance(s)

Selection Criteria:

• Due to limited numbers of vouchers, priority will be given to application with highest demonstrated need and date when received.
• Students currently receiving SNAP benefits are not eligible.
• We highly encourage students not already receiving SNAP to check their eligibility with C3 staff. Proof of acceptance or denial of benefits may be required.

First Name: Last Name: M number: E-mail address:

Pell Eligible

Yes No

Tap Eligible

Yes No

Need for Additional Services

Yes No

Please List Any or All Exigent Circumstances (housing insecurities, transportation issues, need for child care, etc.):

Terms and Conditions: :

•  $50.00 Food Vouchers will be distributed as determined by C3 Staff.
• Unused voucher amount can be carried into subsequent weeks
• Vouchers to be redeemed at Your Bargain Grocer
• 1110 Lincoln Ave, Utica NY 13502

• Treat your vouchers like cash. Lost or stolen vouchers will not be replaced or refunded.
• Vouchers cannot be redeemed for cash, reloaded, returned for a refund or have their balances consolidated to a new voucher. Cash will not be given for any unused amount.

           
For more information about Your Bargain Grocer including hours of operations and specials, please visit http://www.yourbargaingrocer.com/ or visit their Facebook page.

IT IS UNDERSTOOD AND AGREED THAT THE C3/YOUR BARGAIN GROCER PARTICIPANT ACCEPTS AND AGREES TO THE TERMS OF THE VOUCHER AND POLICIES OF YOUR BARGAIN GROCER.

Signature(Please type your name):