Household Size |
Yearly Income |
Monthly income |
weekly Income |
| 1 |
$21,659 |
$1,733 |
$416 |
| 2 |
$29,139 |
$2,333 |
$560 |
| 3 |
$36,619 |
$2,933 |
$704 |
| 4 |
$44,099 |
$3,533 |
$848 |
| 5 |
$51,579 |
$4,133 |
$991 |
| 6 |
$59,059 |
$4,733 |
$1,135 |
| 7 |
$66,539 |
$5,333 |
$1,279 |
| 8 |
$74,019 |
$5,933 |
$1,423 |
| 9 |
$81,499 |
$6,533 |
$1,567 |
| 10 |
$88,979 |
$7,133 |
$1,711 |
| For each additional person add: |
$7,479 |
$623 |
$143 |
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The table to the left shows 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. This certification form is being completed in connection with the distribution of food from the state funded program and/or Federal assistance through The Emergency Food Assistance program.
I certify that my current gross household income is at or below the income listed on this form for households with the same number of people as my household. I also certify that, as of today, my household lives in the area served by this agency. 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 for the value of the food improperly issued to me and may subject me to criminal prosecution under State and Federal law.
(Required)
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 Avenue SW, Washington DC 20250-9410 or call 202-720-5964 (voice TDD). USDA is an equal opportunity provider and employer.
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