Client Info

In order to comply with current regulations, we need some additional information from each person that we serve. Please complete the questions below. You may either enter your information online before printing, or print the blank form now and fill it in by hand later. Thanks!

Ecumenical Food Pantry
Eligibility Form

Any family eligible for Head Start or for free or subsidized meals at school are eligible for services at the food pantry.

For each person in your household, please enter the name and birthdate:

Please PRINT First and Last Name Birthdate Relationship
 
 
 
     
     
     
     
     
     
     
     
Do you receive food stamps? Yes   No

What is your monthly household income? $

Is there anyone you would like to authorize to pick up your food? If so, please enter that person’s name here:

Authorized Person:

Additional authorized person:

Are you currently working? Yes   No

Proof of residency: ID Type

EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP)
ELIGIBILITY TO TAKE FOOD HOME
Name:    
Address: 
         
Number of people in 
Household: 
Telephone: 
           (Optional)

This table shows a yearly 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.

State of Maine TEFAP Income Guidelines

July 1, 2017 to June 30, 2018
150% of Maine Poverty Guidelines

Household Size Annual Month Week
1 $18,090 $1,508 $348
2 $24,360 $2,030 $469
3 $30,630 $2,553 $589
4 $36,900 $3,075 $710
5 $43,170 $3,598 $830
6 $49,440 $4,120 $951
7 $55,710 $4,643 $1,071
8 $61,980 $5,165 $1,192
For Each Additional Add $6,270 $654 $121

You may also be eligible to receive food from TEFAP if your income is greater than that shown in the above table providing you are unable to meet the nutritional needs of your household due to an emergency situation.

Please read the following statement carefully and then sign the form with today’s date.

I certify that my annual household gross income is at or below the income listed on this form for households with the same number of people as my household or that the household’s nutritional needs are not being met due to an emergency situation or that I have established eligibility in one of the following: a) LIHEAP; b) TANF; c) SSI; d) Medicaid; e) Elderly Low Cost Drug Program; f) Elderly Tax and Rent Refund; or g) SNAP (formerly food stamps). 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 law.


(Signature)

(Date)

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, Room 326-W, Whitten Building, 1400 Independence Ave., SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.