Letter Of Proxy Form-Stark County Hunger Task Force printable pdf download

Letter Of Proxy Form-Stark County Hunger Task Force

Letter of Proxy*

Date

(First and Last Name of Client)

(Client’s Address)

(Client’s City), (Client’s State) (Client’s Zip)

(Client’s Phone Number)

Number of People in Household by age:

Age 60+: ____

Age 18 – 59: ____

Age birth – 17 :____

Total: ____

To: Stark County Hunger Task Force

From: (First and Last Name of Client)

This letter is to certify that my household meets the current income guidelines for food

assistance according to the “Federal and State Funded Food Programs Eligibility to Take Food

Home Form.” I am not able to appear in person due to health issues or scheduling conflicts to

obtain the food. Therefore, I hereby give permission to the person(s) listed below to sign my

Ohio Department of Job and Family Services FEDERAL AND STATE FUNDED FOOD PROGRAMS

ELIGIBILITY TO TAKE FOOD HOME (TEFAP) Form in my absence:

(Proxy Name)

(Proxy Complete Address)

If you have any questions or concerns regarding my eligibility or any of the information

provided above, you may contact me at the phone number listed. Thank you for your

assistance.

Sincerely,

(Signature of Client)

(Date Signed)

*MUST BE UPDATED ANNUALLY AND/OR IF HOUSEHOLD COMPOSITION CHANGES

Letter Of Proxy Form-Stark County Hunger Task Force