“FOOD WITH LOVE” REVIVAL CHRISTIAN CHURCH “Self Declaration of Need” Effective June 1, 2024 TO June 30, 2025The Emergency Food Assistance Program is operated in accordance with United States Department of Agriculture (USDA) policy, which prohibits discrimination on the basis of race, color, national origin, sex, age or disability. Eligibility is based upon the income guidelines listed below.Date MM slash DD slash YYYY Recipient Name:(Required) Name Last name Phone:(Required)Address(Required) Street Address: City State Zip Eligibility is based upon the income guidelines listed below. The recipient choose one that applies to their Household Size, understanding they must be at, or below, the income level indicated to be eligible for program benefits.Adults (18-59) live in the household? 1 2 3 4 5 Children (0-17) in the household? 1 2 3 4 5 Adults Seniors (60 and up) in the household? 1 2 3 4 5 The recipient choose one that applies to their Household Size, understanding they must be at, or below, the income level indicated to be eligible for program benefits. Total Household Income (based on 185% of Poverty)Seleccione el tamaño de la familia y los ingresos aproximados ANUAL / MENSUAL / SEMANAL. ***Por cada miembro de la familia adicional añade: Anual $ 9,953 Mensual $ 830 Semanal $ 192(Required) Household Size 1 / Income: Annual $ 27,861 – Monthly $ 2,322 – Weekly $ 536 Household Size 2 / Income: Annual $ 37,814 – Monthly $ 3,151 – Weekly $ 727 Household Size 3 / Income: Annual $ 47,767 – Monthly $ 3,981 – Weekly $ 919 Household Size 4 / Income: Annual $ 57,720 – Monthly $ 4,810 – Weekly $ 1,110 Household Size 5 / Income: Annual $ 67,673 – Monthly $ 5,640 – Weekly $ 1,302 Household Size 6 / Income: Annual $ 77,626 – Monthly $ 6,469 – Weekly $ 1,493 Household Size 7 / Income: Annual $ 87,579 – Monthly $ 7,299 – Weekly $ 1,685 Household Size 8 / Income: Annual $ 97,532 – Monthly $ 8,128 – Weekly $ 1,876 Other I understand the household income limitations and hereby certify that my household size and income make me eligible for participation in the program. I also certify that, as of today, my household lives in the area served by Pennsylvania in The Emergency Food Assistance Program. This certification form is being completed in connection with the receipt of Federal assistance.USDA Nondiscrimination StatementIn accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. "FOOD WITH LOVE" Proxy FormI hereby authorize THIS PERSON to pick up my "FOOD WITH LOVE" Package and deliver it to me. Name Last name Comments:
