Form Il 444-4510 - Emergency Food Program Proxy Statement
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1State of Illinois - Department of Human Services
EMERGENCY FOOD PROGRAM PROXY STATEMENT -
Receipt of Pantry Commodities State Fiscal Year 2017
INCOME ELIGIBILITY BASED ON 185% OF THE FEDERAL POVERTY GUIDELINE
This proxy is for the individual who has disabling conditions which make pick-up of pantry commodities by
the recipient impossible. It may also be used to serve those whose work hours conflict with those of
scheduled distribution of USDA commodities.
Please Print
Name of Recipient:
Address:
City:
State:
Zip Code:
SNAP Recipient? (Supplemental
Yes
Household
Number of children in household
Nutrition Assistance Program)
Size:
18 years or younger?
No
Please check only one box.
Proxy:
Designated Delivery Person
Name of Pantry:
Address of Pantry:
City:
State:
Zip Code:
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the
USDA, its Agencies, offices and employees, and institutions participating in or administering USDA programs are prohibited from
discriminating based on race, color, national origin, sex, disability, age or reprisal or retaliation for prior civil rights activity in any
program or activity conducted or funded by USDA.
Willful diversion of USDA commodities for
DHS MAXIMUM MONTHLY GROSS
personal gain is a state and federal offense
INCOME FOR RECEIPT OF COMMODITIES
subject to a fine of up to $25,000 and/or
INCOME GUIDELINES FOR SFY 2017
imprisonment of up to 5 years.
(JULY 1, 2016 THROUGH JUNE 30, 2017)
I CERTIFY WITH MY SIGNATURE THAT:
Household
Monthly
Household
Monthly
My household monthly gross income does not
Size
Income
Size
Income
exceed DHS established limits; the information
1
$1,832
5
$4,385
I have provided above is accurate and true; I
will
use
food
received
for
household
2
$2,470
6
$5,023
consumption only; and I release USDA, the
3
$3,108
7
$5,663
State of Illinois and any agency or person
distributing food from all liabilities resulting
4
$3,746
8
$6,304
from receipt of food.
For households with more than 8 persons, add $641 for
each additional person
Signature of Recipient
Date
Signature of Proxy
Date
Signature of Pantry Personnel
Date
This Institution is an Equal Opportunity Provider
IL 444-4510 (R-02-16) Emergency Food Program Proxy Statement
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