State of California – Health and Human Services Agency
California Department of Social Services
Dear Applicant,
Welcome to the food assistance program from IMACA. This program is for residents of Inyo or Mono counties in California. In order to better help you and your family, we ask that you take a few minutes to complete this short form. Your response IN NO WAY will affect your receiving food today or in the future. We ask these questions as a way to get to know you and to understand how we can better meet the needs of our community. If you have any questions or concerns, please do not hesitate to ask any food bank staff member or volunteer. Thank you and have a great day!
For income eligibility, you must self-certify that your gross monthly income does not exceed the ceiling listed below for your family size:
TEFAP MAXIMUM INCOME
| HOUSEHOLD SIZE | MONTHLY HOUSEHOLD INCOME | ANNUAL HOUSEHOLD INCOME |
| 1 | $2,949.25 | $35,391 |
| 2 | $4,002.83 | $48,034 |
| 3 | $5,056.42 | $60,677 |
| 4 | $6,110.00 | $73,320 |
| 5 | $6,967.75 | $83,613 |
| 6 | $8,217.17 | $98,606 |
| 7 | $9,270.75 | $111,249 |
| 8 | $10,324.33 | $123,892 |
| Over 8 | Add $1,053.59 each | Add $12,643 each |
This institution is an equal opportunity provider.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audio tape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter 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;
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov.