Letter of Proxy

Letter of Proxy Form

For Food Assistance Program

Personal Information

First and Last
Your Primary Phone Number
Your email address
Client Address
Street Address
Apt./Building/Suite #
City
State/Province
Zip/Postal

Number of People in Household by age:

Letter of Proxy

To:
Agency 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:

First and Last Name
Proxy's Address
Street Address
Apt./Building/Suite #
City
State/Province
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,

*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.