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Bureau of Food Distribution

The Emergency Food Assistance Prgram (TEFAP)

"Self Declaration of Need"
Effictive July 1, 2023 to June 30th, 2024

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Please list up to two proxies. Proxies can not be employees or volunteers of the food bank.*

The Emergency Food Assistance Program is operated in accordance with the United States Department of Agriculture (USDA) policy, which prohibits discrimination on the basis of race, color, national origin, sex, age, or disability. Eligibility is based on the income guidelines listed below.

Family Size	$ Annual	$ Monthly	$ Weekly
1	$ 26,973	$ 2,248	$ 519
2	$ 36,482	$ 3,040	$ 702
3	$ 45,991	$ 3,833	$ 884
4	$ 55,500	$ 4,625	$ 1,067
5	$ 65,009	$ 5,417	$ 1,250
6	$ 74,518	$ 6,210	$ 1,433
7	$ 84,027	$ 7,002	$ 1,616
8	$ 93,536	$ 7,795	$ 1,799
Each additional household member, add
	$ 9,509	$ 792	$ 183

Consent*

I agree to the following:

By checking this box you agree to and verify your household size & household income to the best of your ability. Upon signing your application in person you will be asked to confirm this information once again.

Household Size

Number of Children (0-17)

Number of Adults

Number of Seniors (60+)

Consent*

By checking this box you agree to the following terms:

I understand the household income limitations and hereby certify that my household size and income make me eligible for participation in the program. I also certify that as of today, my household lives in the area served by Pennsylvania in the Emergency Food Assistance Program. This certification form is being completed in the connection with the receipt of Federal assistance.

I understand that making a false statement may result in my having to pay for the value of the food improperly issued to me and may subject me to criminal prosecutions under state and federal law.

Lastly, this form alone does not represent your entire application. Upon submission, an NHN Food Bank representative will be in touch with you to obtain further information as well as a complete USDA application.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, 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: How to File a Complaint, and at any USDA office, 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:

mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;

fax: (202) 690-7442; or

email: program.intake@usda.gov.

This institution is an equal opportunity provider.

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