Download EFAP Sign-in Form - Second Harvest Food Bank of Orange County

STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
'CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
EMERGENCY FOOD ASSISTANCE PROGRAM (EFAP) CERTIFICATION OF ELIGIBILITY
CERTIFICACION DE ELEGIBILIDAD PARA EL PROGRAMA DE ASISTENCIA PARA RECIBIR ALIMENTOS EN CASO DE EMERGENCIA (EFAP)
PARA USO DEL LUGAR DE DISTRIBUTION
FOOD DISTRIBUTION AGENCY
Distribution Date
Page______of______
Second Harvest Food Bank of Orange County
Subdistribution:
Contact Name
Contact Phone
Agency Site #
(949)653-2900
I certify under penalty of perjury that my household
'Certifico bajo pena de perjurio que durante los ultimos 30
income for the past 30 days does not exceed the
'dias, los ingresos de mi hogar no excedieron las normas
NUMBER OF
Emergency Food Assistances Program's (EFAP)
'mensuales colocados en un lugar visible por el Programa
PERSONS
posted monthly guidelines or for the past twelve
'de Asistencia para Recibir Alimentos en Caso de Emer-
IN HOUSE-
does not exceed the annual guidelines. Commodities
are for my personal home use, not to be sold,
'gencia (EFAP), ni tampoco excedieron las normas anuales
'durante los ultimos 12 meses. Los productos que reciba
traded or given away.
son para mi uso personal en mi hogar, no se deben ven'der, cambiar ni regalar.
SIGNATURE
FIRMA
HOLD
NUMERO DE
PERSONAS
ADDRESS
ZIP CODE
EN EL
DIRECCION
CONDIGO POSTAL
HOGAR
EFA 7A (B) (SP) (11/99) (05/05)
TOTAL
u:/share/tefap/forms/excel/EFA-7 Sign-In.XLS