pantry intake form - household application for usda foods

PANTRY INTAKE FORM

HOUSEHOLD APPLICATION FOR USDA FOODS

Name of Household Member: ___________________________________________________________________________________

Number of People in Household: ____________________________________ Date of Birth*:______________________________

Address: ___________________________________________________________ City_______________________Zip______________

Phone Number*: ________________________________________________________________________________________________

(*Participant will receive USDA Foods through TEFAP even if a participant refuses to provide their date of birth or phone number)

Name of Proxy (if applicable): ____________________________________________________________________________________

Address of Proxy: ___________________________________________________City_______________________Zip______________

This person is designated to pick up food on behalf of the eligible household. The proxy must show ID every time

they pick up on behalf of the eligible household.

If the household receives other assistance, mark the appropriate choice(s) below and skip the “Total Household

Income” and crisis situation sections.

___ Supplemental Nutrition Assistance Program (SNAP) ___ Supplemental Security Income (SSI)

___ Temporary Assistance for Needy Families (TANF) ___ Medicaid

___ National School Lunch Program (NSLP) (free or reduced-price meals)

Total Household Income: $ ____________________ per ________________________

The Emergency Food Assistance Program (TEFAP) Income Eligibility Guidelines

July 1, 2024 – June 30, 2025

Based on 185% of Federal Poverty Guidelines

Household Size Annual Income Monthly Income

Twice-Monthly

Income

Bi-Weekly Income Weekly Income

1 $27,861 $2,322 $1,161 $1,072 $536

2 $37,814 $3,152 $1,576 $1,455 $728

3 $47,767 $3,981 $1,991 $1,838 $919

4 $57,720 $4,810 $2,405 $2,220 $1,110

5 $67,673 $5,640 $2,820 $2,603 $1,302

6 $77,626 $6,469 $3,235 $2,986 $1,493

7 $87,579 $7,299 $3,650 $3,369 $1,685

8 $97,532 $8,128 $4,064 $3,752 $1,876

For each additional

household member, add:

+$9,953 +$830 +$415 +$383 +$192

ANSWER ONLY if your household does not receive the government assistance listed above AND your income

does not fall within the USDA income guidelines above: Was there a crisis situation that caused you to need food?

O Yes O No If yes, please state the situation: _________________________________________________________________

The USDA Certiﬁcation period is up to twelve months. For crisis food need the certiﬁcation period is up to six months. Texas

Department of Agriculture can approve crisis food need for seven to twelve months.

CONTINUED ON REVERSE

PANTRY INTAKE FORM

HOUSEHOLD APPLICATION FOR USDA FOODS

CONTINUED FROM REVERSE

(1) I am a member of the household living at the address provided in Section II and that, on behalf of the household, I

apply for USDA Foods that are distributed through The Emergency Food Assistance Program;

(2) all information provided to the agency determining my household’s eligibility is, to the best of my knowledge and

belief, true and correct; and

(3) if applicable, the information provided by the household’s proxy is, to the best of my knowledge and belief, true

and correct.

INTAKE STAFF OR VOLUNTEER ONLY:

USDA Certiﬁcation Period: ____ /____ / _____ to ____ /____ / _____ Certiﬁer’s Signature: ________________________ Date: ____/____/____

Household is eligible based on the following (check appropriate option):

O Receives government assistance listed above O Low income O Crisis food need

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies,

the USDA, its Agencies, oces, 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.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print,

audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for beneﬁts.

Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at

(800) 877-8339. Additionally, program information may be made available in languages other than English.

To ﬁle a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027)

found online at: https://www.usda.gov/oascr/how-to-ﬁle-a-program-discrimination-complaint, and at any USDA oce, or

write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of

the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1) mail: U.S. Department of Agriculture

Oce of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW

Washington, D.C. 20250-9410

This institution is an equal opportunity provider.

(2) fax: (202) 690-7442; or (3) email: [email protected].

Revised June 2024