Alternative Pick Up Form

THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP) 2021 INCOME GUIDELINES

TEFAP MAXIMUM INCOME

Date*
MM
DD
YYYY
Name*
First Last
Phone
Email
I hereby authorize the person with the following name, to pick up my United States Department of Agriculture The Emergency Food Assistance Program (TEFAP) commodities as I am unable to do so:*
Certification*
I certify under penalty of perjury that my household income for the past 30 days does not exceed the TEFAP monthly guidelines, or for the past twelve months does not exceed the annual guidelines and that the number listed for my household size is true and correct. Commodities are for my personal home use, not to be sold, traded, or given away.
Address*
Street Address City ZIP / Postal Code
Number of people in household*
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