State of Illinois Department of Human Services
INCOME ELIGIBILITY CHANGE EFFECTIVE 2/8/2012
EMERGENCY FOOD PROGRAM PROXY STATEMENT Receipt of Pantry Commodities State Fiscal Year 2013 INCREASE IN INCOME ELIGIBILITY FROM 130% TO 185% OF THE FEDERAL POVERTY GUIDELINE
This proxy is for the individual who has disabling conditions which make pick-up of pantry commodities by the recipient impossible. It may also be used to serve those whose work hours conflict with those of scheduled distribution of USDA commodities. Please Print Name of Recipient: Address: City:
Zip Code:
State:
ONLY REQUIRED FOR RECEIPT OF TANF FOOD Household Size:
Number of children 18 years or younger in household
Proxy: Designated Delivery Person
Name of Pantry:
Loaves & Fishes Community Pantry
Address of Pantry:
1871 High Grove Lane
City:
_Naperville
State:
IL
Zip Code: 6054 0
Do you currently receive SNAP (formerly known as Food Stamps)?
Yes
No
Please check one box.
Willful diversion of USDA commodities for personal gain is a state and federal offense subject to a fine of up to $25,000 and/or imprisonment of up to 5 years.
OHS MAXIMUM MONTHLY GROSS INCOME FOR RECEIPT OF COMMODITIES INCOME GUIDELINES FOR SFY 2013 (JULY 1, 2012 THROUGH JUNE 30, 2013) INCOME ELIGIBILITY CHANGE EFFECTIVE: 2/8/2012
I CERTIFY WITH MY SIGNATURE THAT: My household monthly gross income does not exceed DHS established limits; the information I have provided above is accurate and true; I will use food received for household consumption only; and I will release USDA. the State of Illinois and any agency or person distributing food from all liabilities resulting from receipt of food.
HOUSEHOLD SIZE
MONTHLY INCOME
HOUSEHOLD SIZE
MONTHLY INCOME
1
$1,722
5
$4,164
2
$2,333
6
$4,775
3
$2,943
7
$5,385
4
$3,554
8
$5,996
For each additional household member add $611
Signature of Recipient Signature of Proxy
Date Signature of Pantry Personnel This Institution is an Equal Opportunity Provider
IL 444-4510 (R-03-12) Emergency Food Program Proxy Statement Printed by Authority of the State of Illinois 4,500 copies P.O. #12-1112
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Estado de Illinois Departamento de Servicios Humanos
CAMBIO DE ELEGIBILIDAD DE INGRESOS EFFECTIVO 2/8/2012
DECLARACION DEL PODERHABIENTE - PROGRAMA ALIMENTOS DE EMERGENCIA - Recibo pare Alimentos de Despensa Alio Fiscal 2013 AUMENTO EN LA ELEGIBILIDAD DE INGRESOS del 130 % AL 185 % DEL NIVEL FEDERAL DE POBREZA
Este poder es para el individuo que tiene una condicion de discapacidad que le impide recoger alimentos de una despensa. Tambien puede ser usado por aquellos que sus horarios de trabajo interfieren con el horario de distribucion de alimentos del USDA. Por Favor Escriba con Letra de Molde Nombre del Beneficiario: Direcci6n:
Estado:
Ciudad:
Zona Postal:
SOLO SE REQUIERE PARA RECIBIR ALIMENTOS TANF Taman째 del Hogar:
Numero de ninos de 18 afios o menores en el hogar
Poderhabiente: Persona Designada a Recojer Alimentos
Loaves & Fishes Community Pantry Direcci6n de la Despensa: 1871 High Grove Lane Ciudad: Naperville Estado: IL Zona Postal: 60540 Nombre de la Despensa:
LActualmente, recibe usted beneficios SNAP (antes Estampillas de Comida)?
Si
I I No
Por favor marque uno.
El use intencional de alimentos del USDA para ganancia personal es una ofensa federal y estatal sujeta a una multa por hasta $25,000 y / o prision por hasta 5 arios.
INGRESO BRUTO MENSUAL MAXIMO DEL DHS PARA OBTENER ALIMENTOS NIVEL DE INGRESOS PARA EL ANO FISCAL 2013 (1 DE JULIO 2012 HASTA 30 DE JUNTO 2013) CAMBIO DE ELEGIBILIDAD DE INGRESOS EFFECTIVO: 2/8/2012
YO CERTIFICO CON MI FIRMA QUE: El ingreso bruto de mi hogar no excede el limite establecido por DHS; la informaci6n que he dado es correcta y verdadera; yo usare los alimentos recibidos solo para el consumo de mi hogar; y exonero de cualquier responsabilidad que resulte al recibir alimentos, al USDA, al Estado de Illinois y a cualquier agencia o persona que distribuya los alimentos.
TAMANO DEL HOGAR
INGRESO MENSUAL
TAMANO DEL HOGAR
INGRESO MENSUAL
1
$1,722
5
$4,164
2
$2,333
6
$4,775
3
$2,943
7
$5,385
4
$3,554
8
$5,996
Asada $611 por cada miembro adicional en el hogar
Firma del Beneficiario Firma del Poderhabiente o Apoderado
Fecha Firma del Personal de la Despensa
Esta Institucidn es un Proveedor Que Ofrece Igualdad en las Oportunidades IL 444-4510S (R-03-12) Emergency Food Program Proxy Statement Printed by Authority of the State of Illinois 4,500 copies P.O. #12-1113
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