This table shows yearly gross income for each family size. If your household is at or below the income listed for the number of people in your househol, you are eligible to receive food. The certification form is being completed in connection with the distribuition of food from the state funded program and/or Federal assistance through The Emergency Food Assistance Program. 


In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at:

https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant's name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by: 1. mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or 2. fax: (833)

256-1665 or (202) 690-7442; or email: program .intake@usda.gov This institution is an equal opportunity provider.

FOOD RELEASE AGREEMENT

The food distribution program is a ministry to everyone in need of assistance with food. We aquire foods from various sources that e believe to be reputable establishments. Perishable foods are kept under refrigeration and frozen foos are kept in a freezer at all times.

We request that you examine the contents of these packages of foods and determine if they are still in good and usable conditions. If you determine they have spoiled, please dispose of them. Since the foods are given free of charge to you, there is therefore no personal loss to you.

These foods are given to you in good faith and we will not be held responsible for any harm which comes from their misuse.

By receiving these foods you also agree to obtain the food for your houehold use and agree that they will not be used for goods, money or services.

Authorization by Digital Signature

Read the following statement carefully, then sign the form & fill in today's date.

I certify that my current gross household income is at or below the income listed on this form for households with the same number of people as my household.

I also certify that, as of today, my household lives in the area served by this agency.

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.

I have read, understand and agree with the Liability Release and Authorization. By typing my name I understand this is the act of a digital signature and releases Kings Point Church of God from any and all liabilities.