Foodbank USDA Eligibility Form

Foodbank USDA Foods Program Self-Declaration of Eligibility
* indicates required field
The Income Eligibility Guidelines table shows a yearly gross income for each family size. If your income is at or below the income listed for the number of people in your household, you are eligible to receive USDA Foods.

Please read the following statement carefully, then sign the form and write in today’s date:

I certify that my yearly gross household income is at or below the income listed in the Income Eligibility Guidelines 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 the Vermont Emergency Food Assistance Program. This certification form is being completed in connection with the receipt of Federal assistance. 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.