SHEL DOUGLAS

DEPARTMENT OF SOCIAL SERVICES Director

320 Hospital Drive, Suite 11
FAUQUIER COUNTY Warrenton, VA 20186
(540) 422-8400 Phone
(540) 422-8449 Fax

MEALS ASSISTANCE GIFT CARD REQUEST FORM

SECTION I: APPLICANT AFFI D AVI T

This section must be completed by the applicant prior to issuance of gift card(s). Fauquier County residence is required.

First & Last Name:

Home Address:
Phone Number: # Persons in Family/Household*:

I certify the following statements to be accurate and true: Initials

The number of persons listed for my family/household are immediate family (including myself, spouse and
children – adoptive, biological, foster or step) and currently residing within my household.
I/my immediate family have been impacted by COVID.
I/my immediate family have not already received CARES Act funded assistance as of the date of this
application.

SECTION II: GIFT CARD RECEI PT

This section must be completed by FDSS staff and signed by the recipient(s) prior to issuance of any gift card(s).
Qty. $50 Cards Card Number(s) Qty. $100 Cards Card Number(s)
Airlie
Corner Deli
Covert Café
El Agave (All Locations)
Fosters Grille (All Locations)
Great Harvest
Grioli's Italian Grill and Bistro
Hayfield Farm
Joe's Pizza
Marshall Diner
Messicks Farm Market
Molly's
Northside 29 Restaurant
Old Salem Café
Shawns BBQ
Spitony's Pizza
Whiffle Tree Farm
Whole Ox
Total Cards Issued:
Total Value:

_____________ ____________________________________ ________________________________ ______________

Date Recipient Signature Staff Signature Staff Initials