Client Intake Form Food Bank printable pdf download

Client Intake Form

Name:

Date:

Address:

City:

State:

Zip Code:

Phone Number:

(_______) - ____________________ Number of People in Household:

Yes_____ No _____

Are you on any form of government assistance, Food Stamps/ SNAP, SSI,TANF, NSLP or Non- institutional Medicaid?

Ages of Persons Served:

Infant - 18 ________

19 - 63

64 & Over

TEXCAP INCOME ELIGIBILITY GUIDELINES

July 1, 2013 - June 30, 2014

The chart below provides the income limits for households applying to participate in the TEXCAP program. The first column lists

household by size. The next three columns provide maximum allowable income limes, in annual, monthly, and weekly amounts.

APPLICANT HOUSEHOLD IS NOT ELIGIBLE FOR USDA ITEMS IF THE HOUSEHOLD'S GROSS INCOME EXCEEDS:

Household Size:

Annual:

Monthly: Twice-Monthly

Bi-Weekly

Weekly:

21,257

1,772

$886

$818

409

28,694

2,392

$1,196

$1,104

552

36,131

3,011

$1,506

$1,390

695

43,568

3,631

$1,816

$1,676

838

51,005

4,251

$2,126

$1,962

981

58,442

4,871

$2,436

$2,248

1,124

65,879

5,490

$2,745

$2,534

1,267

73,316

6,110

$3,055

$2,820

1,410

For each additional

person add:

7,437

620

$310

$287

144

Note: Use gross income to determine eligibility. EXCEPTIONS: (1) Farmers and self-employed households qualify on net income (total

income minus expenses). (2) A household with unexpected and unavoidable expense of household crisis may qualify for temporary,

emergency food assistance without regard to the household's gross or net income.

By signing below, I certify that: (1) I am a member of the

Al firmar a continuación, certifico que: (1) soy miembro de la unidad

household living at the address provided in Section I and that,

familiar que vive en la dirección que se da en la Sección I, y que

on behalf of the household, I apply for USDA-donated

solicito en nombre de la unidad familiar los productos básicos

donados por el Departamento de Agricultura de Estados Unidos

commodities that are distributed through the Texas

(USDA) y distribuidos por el Programa de Texas de Asistencia con

Commodity Assistance Program, (2) all information provided to

Productos Básicos, (2) toda la información que le he dado al

the agency determining my household’s eligibility is, to the

departamento que determinará si mi unidad familiar llena los

best of my knowledge and belief, true and correct, and (3) if

requisitos del programa, es, a mi leal saber y entender, verdadera y

applicable, the information provided by the household’s

correcta y (3) si es pertinente, la información presentada por el

“Authorized Representative” (as named below or as authorized

“representante autorizado” de la unidad familiar (como se asigna

on a separate page) is also, to the best of my knowledge and

abajo o como se autoriza en otra hoja) también es verdadera y

belief, true and correct.

correcta a mi leal saber y entender.

Client Signature

Date

Authorized Represenative Signature

Date

Nondiscrimination:

In accordance with federal law and U.S. Department of Agriculture policy, the institution is prohibited from discriminating ont he basis of race, ethnicity, national origin,

age, sex and disability. To file a complain of discrimnation, with USDA, Director, Office of Adjudication and Compliance, 1400 Independence Avenue, SW, Washington,

D.C. 20250-9410 or call 202-260-1026, 1-866-632-992 (toll free) or 1-202-401-0216 (TDD)l

* All FBGC Partner Agencies are required to use this intake form.