Name *

First Name

Last Name

Authorization to receive emails. *

Select One

Yes

No

Phone Number *

(###)

###

####

Authorization to receive text alerts. *

Select One

Yes

No

Do you identify as an individual with mental or physical disabilities? *

This is a medical designation which can be used to better assist you while visiting our program.

Yes

No

Food Allergies

Check all that apply.

Wheat

Nuts

Fish & Shellfish

Eggs

Soy

Sesame

Attesting Your Income - TEFAP FORM *

You are verbally confirming that the following information is true: You are a resident of the State of Connecticut. You are at or below the (yearly) gross income limit for the number of people in your household below: Household of 1- 45,180 Household of 2- 61,320 Household of 3- $77,460 Household of 4- $93,600 Household of 5- $109,740 Household of 6- $125,880 Household of 7- $142,020 Household of 8- $158,160 Income guidelines reflect 300% of the federal poverty limit, last updated on 7/1/2024 You are also eligible to receive TEFAP commodities if your household participates in any of the following programs: Supplemental Nutritional Assistance Program (SNAP), Women, Infants and Children (WIC), Temporary Assistance for Needy Families (TANF or TFA), Energy Assistance, HUSKY Health/Medicaid, Section 8 Rental Assistance Program, State Administered General Assistance (SAGA), and Supplemental Security Income (SSI). *You will report any household or income changes prior to the next visit.

Yes, I attest that I meet the following income requirements.

No I do not, my income exceeds the federal guidelines outlined in the form.