Farm Share, non-profit food-bank, for recovery and distribution of surplus food for hungry people

Farm Share Individual Application

The Emergency Food Assistance Program (TEFAP)

October 1, 2006 - September 30, 2007

* Name		* Number of people in household
* Address
* City		* State
* Zip 5 or 9 digit format		* County
* Phone 1		Phone 2
Alternate Name of person who can pick up for you if you can not.

The following shows a yearly gross income for each family size. If your houshold income is at or below the income listed for the number of people in your household, you are eligible to receive food. The following chart is effective July 1, 2006 through June 30, 2007.

Household Size	Annual Income	Monthly Income	Weekly Income
1	$12,740	$1,062	$245
2	$17,160	$1,430	$330
3	$21,580	$1,799	$415
4	$26,000	$2,167	$500
5	$30,420	$2,535	$585
6	$34,840	$2,904	$670
7	$39,260	$3,272	$755
8	$43,680	$3,640	$840
For each additional family member add	+$4,420	+$369	+$85

You are eligible to receive food from TEFAP if your household meets the income guidelines above or participates in any of the following programs. Please check any category that applies.

	Income Eligibility
	Food Stamps
	Temporary Assistance for Needy Families (TANF)
	Supplemental Security Income (SSI), Medicaid
	Residence in Pubic Housing funded by Municipal, County, State or Federal Government

Terms & Conditions

I certify that my yearly houshold gross income is at or below the income listed on this form for housholds with the same number of people OR that I participate in the program(s) that I have checked on this form. I also certify that as of today, I reside in the State of Florida. This certification is being submitted in connection with the receipt of Federal assistance. Program officials may verify what I have certified to be true. I understand that making a false certification may result in having to pay the State agency for the value of the food improperly issued to me and may subject me to civil or criminal prosecution under State and Federal laws.

* I have read the Terms & Conditions above and meet at least one of the requirements to receive USDA commodities.

* Signature

Date

07/25/2008

This CERTIFICATION IS VALID FOR A PERIOD OF ONE YEAR.

Any changes in the household circumstances must be reported to the distributing agency immediatly.

In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, D.C., 20250-9410 or call (800) 795-3272 (voice) or 202-720-6382 (TTY). USDA is an equal opportunity provider and employer.