Fillable HOUSEHOLD ELIGIBILITY GUIDELINES EFFECTIVE July 1, 2019

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HOUSEHOLD ELIGIBILITY GUIDELINES EFFECTIVE July 1, 2019

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JFS 04221 (Rev. 7/2019)
Ohio Department of Job and Family Services
FEDERAL AND STATE FUNDED FOOD PROGRAMS
ELIGIBILITY TO TAKE FOOD HOME
This box is optional for local
agency use, check one:
A (Household with minor children)
B (Household without minor children)
Name
Address
City
Zip
Area Code + Phone
( )
This table shows yearly gross income for each family size. If your household income is at or below the income listed for the number of people in your household,
you are eligible to receive food. This certification form is being completed in connection with the distribution of food from the state funded program and/or Federal
assistance through The Emergency Food Assistance Program.
HOUSEHOLD ELIGIBILITY GUIDELINES EFFECTIVE July 1, 2019
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: http://www.ascr.usda.gov/complaint_filing_cust.html, 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: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-
9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. This institution is an equal opportunity provider.
This box is optional for local
agency use, check one:
Full Service
Partial Service
Signature
X
Date
X
Full Service
Partial Service
Signature
X
Date
X
Full Service
Partial Service
Signature
X
Date
X
Full Service
Partial Service
Signature
X
Date
X
Full Service
Partial Service
Signature
X
Date
X
Full Service
Partial Service
Signature
X
Date
X
Full Service
Partial Service
Signature
X
Date
X
Full Service
Partial Service
Signature
X
Date
X
Full Service
Partial Service
Signature
X
Date
X
Full Service
Partial Service
Signature
X
Date
X
Full Service
Partial Service
Signature
X
Date
X
Household Size
Yearly
Income
Monthly
Income
Weekly
Income
Read the following statement carefully, then sign the form & write in today’s date.
1
$24,979
$2,081
$480
I certify that my current gross household income is at or below the income listed
on this form for households with the same number of people as my household.
I also certify that, as of today, my household lives in the area served by this
agency. Program officials may verify what I have certified to be true. I
understand that making a false certification may result in having to pay the State
for the value of the food improperly issued to me and may subject me to criminal
prosecution under State and Federal law.
2
$33,819
$2,818
$650
3
$42,659
$3,554
$820
4
$51,499
$4,291
$990
5
$60,339
$5,028
$1,160
6
$69,179
$5,764
$1,330
7
$78,019
$6,501
$1,500
8
$86,859
$7,238
$1,670
Signature
X
Date
X
9
$95,699
$7,974
$1,840
For each additional
household member add
$8,840
$737
$170
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HOUSEHOLD ELIGIBILITY GUIDELINES EFFECTIVE July 1, 2019

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Completed 26 January 2021

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