Form Efa 15 - Alternate Pick-Up Request Form - Emergency Food Assistance Program (Efap) 2017 Income Guidelines

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ALTERNATE PICK-UP REQUEST FORM
EFAP MAXIMUM INCOME
Emergency Food Assistance Program (EFAP)
2017 Income Guidelines
MONTHLY
ANNUAL
HOUSEHOLD
HOUSEHOLD
HOUSEHOLD
SIZE
INCOME
INCOME
Date:____________________________________
$1,507.50
$18,090
1
$2,030.00
$24,360
2
$2,552.50
$30,630
3
Authorization:
I hereby authorize, _________________________________________ to pick up
$3,075.00
$36,900
4
my United States Department of Agriculture Emergency Food Assistance
5
$3,597.50
$43,170
Program (EFAP) commodities as I am unable to do so.
$4,120.00
6
$49,440
$4,642.50
$55,710
7
Certification:
I certify under penalty of perjury that my household income for the past 30 days
$5,165.00
$61,980
8
does not exceed the EFAP monthly guidelines, or for the past twelve months does
$5,687.50
$68,250
9
not exceed the annual guidelines and that the number listed for my
$6,210.00
$74,520
10
household size is true and correct. Commodities are for my personal home use,
Over 10
Add $522.50
Add $6,270
not to be sold, traded, or given away.
each
each
REVISED 4/17
ZIP CODE
NUMBER OF
SIGNATURE
ADDRESS
PEOPLE IN
HOUSEHOLD
EFA 15 (4/17)
CUT HERE
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ALTERNATE PICK-UP REQUEST FORM
EFAP MAXIMUM INCOME
Emergency Food Assistance Program (EFAP)
MONTHLY
ANNUAL
HOUSEHOLD
2017 Income Guidelines
HOUSEHOLD
HOUSEHOLD
SIZE
INCOME
INCOME
Date:____________________________________
1
$1,507.50
$18,090
2
$2,030.00
$24,360
3
$2,552.50
$30,630
Authorization:
4
I hereby authorize, _________________________________________ to pick up
$3,075.00
$36,900
my United States Department of Agriculture Emergency Food Assistance
5
$3,597.50
$43,170
Program (EFAP) commodities as I am unable to do so.
6
$4,120.00
$49,440
7
$4,642.50
$55,710
Certification:
8
$5,165.00
I certify under penalty of perjury that my household income for the past 30 days
$61,980
does not exceed the EFAP monthly guidelines, or for the past twelve months does
9
$5,687.50
$68,250
not exceed the annual guidelines and that the number listed for my
10
$6,210.00
$74,520
household size is true and correct. Commodities are for my personal home use,
Over 10
Add $522.50
Add $6,270
not to be sold, traded, or given away.
each
each
REVISED 4/17
ZIP CODE
NUMBER OF
SIGNATURE
ADDRESS
PEOPLE IN
HOUSEHOLD
EFA 15 (4/17)

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