Intake Form 2

 
 
CHECK ITEMS THAT APPLY: Income and Subsidies Per Month

 

_______ APTD / Cash (Aid to Permanently and Totally Disabled)

_______ CSFP (Commodity Supplemental Food Program)

_______ Food Stamps
_______ Fuel Assistance Program

_______ Medicaid
______ SSA : SSI / SSDI
_______ Subsidized Housing
_______ TANF (Temporary Assistance to Needy Families)

_______ Wages / Salary
________WIC (Women , Infants, and Children)

$__________________.    Estimated GROSS monthly income

 


 

2014 Income Guidelines

Household of:   Yearly Household Income

     1                  $21,590

     2                  $29,101

     3                  $36,612

     4                  $44,123

     5                  $51,634

     6                  $59,145

     7                  $66,656

     8                  $74,167

For each additional family member, add : $7,437

 
 
 

We receive limited USDA commodities that require income qualification. If your income on the grid to the right is below what is noted for your family size, you qualify for our USDA groceries.