State of California – Health and Human Services Agency California Department of Social Services
ALTERNATIVE PICK-UP REQUEST FORM
THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP) 2020 INCOME GUIDELINES
EFA 15 (4/20) Page 1 of 1
Date:__________________________________
TEFAP MAXIMUM INCOME
HOUSEHOLD SIZE
MONTHLY HOUSEHOLD
INCOME
ANNUAL HOUSEHOLD
INCOME
1 $2,498.83 $29,986.00
2 $3,376.17 $40,514.00
3 $4,253.50 $51,042.00
4 $5,130.83 $61,570.00
5 $6,008.17 $72,098.00
6 $6,885.50 $82,626.00
7 $7,762.83 $93,154.00
8 $8,640.17 $103,682.00
9 $9,517.50 $114,210.00
10 $10,394.83 $124,738.00
Over 10 Add $877.33 each Add $10,528.00 each
This institution is an equal opportunity provider.
Authorization:
I hereby authorize, __________________________________ to pick up my United States
Department of Agriculture The Emergency Food Assistance Program (TEFAP) commodities as I am
unable to do so.
Certication:
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.
Signature
Address Zip Code Number of people in household
