TEFAP Eligibility Form October 2015 - September 2016
Name: | |CaseFirstName| |CaseLastName| |
Address: | |CaseAddress1| |
City: | |CaseCity| |
County: | |CaseCounty| |
Number of People in Household: | |TEFAPHHsize| |
Effective October 1, 2015 through September 30, 2016
(Household gross income must be at or below for appropriate size household.)
Household Size | Per Year | Per Month | Per Week |
1 | $23,544 | $1,962 | $453 |
2 | $31,872 | $2,656 | $613 |
3 | $40,200 | $3,350 | $773 |
4 | $48,504 | $4,042 | $933 |
5 | $56,832 | $4,736 | $1,093 |
6 | $65,160 | $5,430 | $1,253 |
7 | $73,464 | $6,122 | $1,413 |
8 | $81,792 | $6,816 | $1,573 |
Each Additional Family Member | $8,328 | $694 | $160 |
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The above table to the left shows a gross income for each family size. If your household income
is at or below the income listed for the number of people in your household,
you are eligible to receive food.
A household is defined as a group of people who live together and share money and other resources
in order to get food. Please look at the income scale to the left to determine if your household
is eligible for TEFAP.
OR
If you currently participate in a Foor & Nutrition Services Program (i.e. Food Stamps) you are automatically
eligible to receive TEFAP nd do not need to look at the income scale.
Note:
The above may be read to persons who are unable to read. People who are unable to sign their name may sign
by using an X.
Please read the following statement carefully, then sign the form and write in today's date.
I understand that any misrepresentation of need, sale, or misuse of the foods I have received is prohibited and could result in a fine, imprisonment, or both. (Sec. 211 E, PL 96-494 and Sec. 4C, PL 93-86 as amended.)
The section below is only for homebound individuals.
The following persons are authorized to pick up my food (if applicable):
Authorized Representative: | |TEFAPauth1| |
Authorized Representative: | |TEFAPauth2| |
|TEFAPclientSig| | |TEFAPclientSigDate| |
_______________________ | _________________ |
(Client Signature) | (Date) |
The U.S. Department of Agriculture (USDA) prohibits discrimination
against its customers, employees, and applicants for employment on
the bases of race, color, national origin, age, disability, sex,
gender identity, religion, reprisal, and where applicable, political
beliefs, marital status, familial or parental status, sexual
orientation, or if all or part of an individual`s income is derived
from any public assistance program, or protected genetic information
in employment or in any program or activity conducted or funded by
the Department. (Not all prohibited bases will apply to all programs
and/or employment activities.)
If you wish to file a Civil Rights program complaint of discrimination,
complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html,
or at any USDA office, or call (866) 632-9992 to request the form.
You may also write a letter containing all of the information
requested in the form. Send your completed complaint form or letter
to us by mail at U.S. Department of Agriculture, Director, Office of
Adjudication, 1400 Independence Avenue( S.W., Washington, D.C.
20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov
Individuals who are deaf, hard of hearing or have speech disabilities may contact
USDA through the Federal Relay Service at (800) 877-8339; or (800)
845-6136 (in Spanish). USDA is an equal opportunity provider and
employer.
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