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Food Assistance Program
Self Declaratory Form - Household Eligibility Form
Name of head of household
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Income Eligibility
The table below shows a 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.
Household Size: The number of people living in your household
*
Rows
#
Number of Elderly (60+) persons living in your household
0
1
2
3
4
5
6
7
8
9
Number of disabled persons living in your household
0
1
2
3
4
5
6
7
8
9
Number of children (under 18) living in your household
0
1
2
3
4
5
6
7
8
9
Number of adults (18-59) living in your household
0
1
2
3
4
5
6
7
8
9
For each addtional person add $15,420 (e.g. 9 people $117,481)
Annual Income for your household?
*
Total annual household income for everyone living in the house. example
Is your child enrolled in any of these Jericho Programs?
Afterschool Learning Program
Summer Learning Program
Mentoring Program
Discovery Summer Program (HS only)
None of the above
Please check each programs you already participate in:
*
Food Stamps
Energy Assistance
WIC
School Meals
Husky part A, Part B
State Administred General Assistance (SAGA)
Temporary Assistance to Needy Families (TANF)
Aid to the Blind or Disabled
Social Secuirty Supplemental (SSI)
Section 8 Rental Assistance Program
NONE of the Above
Upload ID (Driver's License or passport) for head of household
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Upload address verification for head of household: Driver's License, utility bill or lease
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Upload ID (driver's license or passport) for all other adults(18+) living in the household, including anyone elderly or disabled.
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Upload Income Verification for head of household and any members who receive income (paystub, employer letter on letterhead, or current tax document). If, you're part of any of the public assistance programs named above, you do NOT need to provide income verification.
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Upload ID for children, insurance card, birth certificate, School ID.
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Please read the below statement, check and sign the form.
*
Signature
*
Name of Person Signing
First Name
Last Name
Relationship to the head of the household
Please Select
self
spouse
relative
child
other
Today's Date
Submit
Should be Empty: