Form Efa 7a Eng/sp - Emergency Food Assistance Program (Efap) Certification Of Eligibility

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STATE OF CALIFORNIA—HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
EMERGENCY FOOD ASSISTANCE PROGRAM (EFAP) CERTIFICATION OF ELIGIBILITY
CERTIFICACIÓN DE ELEGIBILIDAD PARA EL PROGRAMA DE ASISTENCIA PARA RECIBIR
ALIMENTOS EN CASO DE EMERGENCIA (EFAP)
FOOD DISTRIBUTION AGENCY NAME/ NOMBRE DE LA OFICINA/AGENCIA DE DISTRIBUCIÓN DE ALIMENTOS:
DISTRIBUTION DATE & TIME /FECHA Y HORA DE DISTRIBUCIÓN:
Page /Página _____ of/ de ______
DISTRIBUTION SITE ADDRESS /DIRECCIÓN DEL LUGAR DE DISTRIBUCI ÓN :
CONTACT NAME /NOMBRE DEL CONTACTO:
CONTACT PHONE /TELÉFONO DEL CONTACTO:
(
)
CERTIFICACIÓN
CERTIFICATION
Certifico bajo pena de perjurio que durante los últimos
I certify under penalty of perjury that my household
30 días, los ingresos de mi hogar no excedieron las
income for the past 30 days does not exceed the
Is this
normas mensuales del Programa de EFAP, las cuales
Emergency Food Assistance Program’s (EFAP) posted
Number of
your first
están colocadas en un lugar visible, y tampoco
monthly guidelines, or for the past twelve months does not
people in
visit this
excedieron las normas anuales durante los últimos 12
exceed the annual guidelines and that the number listed
household
month?
meses. También certifico que el número de personas
for my household size is true and correct. Commodities
en mi hogar, como yo lo indico en este formulario, es
are for my personal home use, not to be sold, traded, or
verdadero y correcto. Los alimentos/productos que yo
Número
given away.
¿Es ésta
reciba son para uso personal en mi hogar y no se
de
su
deben vender, cambiar, ni regalar.
personas
primera
en el
visita del
ADDRESS
SIGNATURE
ZIP CODE
hogar
mes?
CÓDIGO
DIRECCIÓN
FIRMA
POSTAL
1.
No
Yes/ Sí
2.
No
Yes/ Sí
3.
No
Yes/ Sí
4.
No
Yes/ Sí
5.
No
Yes/ Sí
6.
No
Yes/ Sí
7.
No
Yes/ Sí
8.
No
Yes/ Sí
9.
Yes/ Sí
No
10.
No
Yes/ Sí
11.
No
Yes/ Sí
12.
No
Yes/ Sí
13.
No
Yes/ Sí
14.
No
Yes/ Sí
15.
No
Yes/ Sí
16.
No
Yes/ Sí
17.
No
Yes/ Sí
18.
No
Yes/ Sí
19.
No
Yes/ Sí
20.
Yes/ Sí
No
21.
No
Yes/ Sí
22.
No
Yes/ Sí
23.
No
Yes/ Sí
24.
No
Yes/ Sí
25.
No
Yes/ Sí
TOTALS:
TOTALES:
EFA 7A (ENG/SP) (3/11) EMERGENCY FOOD ASSISTANCE PROGRAM

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