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Exhibit E (Rev. 07/09)

THE EMERGENCY FOOD ASSISTANCE PROGRAM

Declaratory Statement/Inventory Control

Organization: ___________________________________________________________

I, the undersigned, affirm and declare all of the following:

The income of my household does not exceed the monthly Income Guidelines below
Household Size	Maximum Income	Household Size	Maximum Income	Household Size	(130% of the Federal Poverty Level):
1	$1,174	3	$1,984	5	Maximum Income	Household Size	Maximum Income	For Each Additional Family Member, Add:
2	$1,579	4	$2,389	6	$2,794	7	$3,605	$406

I will use USDA commodities for home consumption only.
I will not sell, barter, or inappropriately utilize USDA commodities in any manner.
I will not attempt to receive the same type of USDA commodities from more than one organization during any given month.
I understand that anyone who willfully and/or intentionally makes a false statement, conceals or withholds information in order to receive food they are not eligible to receive may be

subject to prosecution, ineligibility penalties and restrictions.

$3,200

$4,010

Section I:
Eligibility (Complete BEFORE Distribution)

Section II:
Distribution/Inventory (Complete at Distribution)

Date

Household Size

Household Address

*Signature of household
member or authorized

Representative *Read above
statement before signing

Inventory

Starting Balance

Number of
Packages
Distributed

Initials of Distributing

Agent

Initials of Recipient Verifying

Receipt

Total Households

Total on Hand

Total Distributed

This institution is an equal opportunity provider.

8-E