Letter of Proxy Letter of Proxy Form For Food Assistance Program Personal Information Date * Client Name * First and Last Client Phone Number * Your Primary Phone Number Email Address (optional) Your email address Client Address * Client Address Your Street Address Your Street Address Apt./Building/Suite # Apt./Building/Suite # City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Number of People in Household by age: Age 60+ * Age 18 – 59 * Age birth – 17 * Total # in household: * Letter of Proxy Agency Name To: Client Name * From: First and Last This letter is to certify that my household meets the current income guidelines for food assistance according to the “Federal and State Funded Food Programs Eligibility to Take Food Home Form.” I am not able to appear in person due to health issues or scheduling conflicts to obtain the food. Therefore, I hereby give permission to the person(s) listed below to sign my Ohio Department of Job and Family Services FEDERAL AND STATE FUNDED FOOD PROGRAMS ELIGIBILITY TO TAKE FOOD HOME (TEFAP) Form in my absence: Proxy's Name * First and Last Name Proxy's Address * Proxy's Address Proxy's Street Address Proxy's Street Address Apt./Building/Suite # Apt./Building/Suite # City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal If you have any questions or concerns regarding my eligibility or any of the information provided above, you may contact me at the phone number listed above. Thank you for your assistance. Sincerely, Client Signature * Clear *MUST BE UPDATE ANNUALLY AND/OR IF HOUSEHOLD COMPOSITION CHANGES. Form MUST BE accompanied by a photo copy of the client's ID. A photo on your cell phone of their driver's license will suffice. Submit
