Disclaimers: Please read the following statement carefully. Then sign the form and write in today’s date.
I certify that my yearly gross household income is at or below the income listed on this form for households with the same number of people as my household, OR that my household participates in the program that I have checked on this form. I also certify that, as of today, my household lives in the area served by the ALABAMA EMERGENCY FOOD ASSISTANCE PROGRAM. This certification form is being completed in connection with the receipt of federal assistance. 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.
CCDN is assisting me with life services food, clothes, and/or both. I am aware that CCDN only assists with life services on Thursdays ONLY between the hours of 1:00 pm-3:00 pm. We do not guarantee financial resources only connection resources.