OXFORD ECUMENICAL FOOD SHELF ANNUAL CENSUS

The information provided below determines eligibility to receive a specific amount of food. Only valid identifications will be used to determine the household size.  Proof for family members may include a birth certificate, social security card, drivers license or passport, etc.

Note: To guarantee confidentiality family names are never reported to anyone.

ID#______Name: ___________________________________Date:__________           

Number of individuals between           Ages of 0 – 4            #_______

Gender (M or F)        Age as of 01/01/12            Date of Birth

__________                _______________             ___________  

__________                _______________             ___________

__________                _______________             ___________

__________                _______________             ___________ 

Number of individuals between           Ages of 5 – 17          #_______

__________                _______________             ___________

__________                _______________             ___________

__________                _______________             ___________

__________                _______________             ___________

__________                _______________             ___________

__________                _______________             ___________

Number of individuals between           Ages of 18 – 64        #_______

__________                _______________             ___________

__________                _______________             ___________

__________                _______________             ___________

__________                _______________             ___________

__________                _______________             ___________

Number of individuals between           Ages over 65            #_______

__________                _______________             ___________

__________                _______________             ___________

__________                _______________             ___________

Signature                                                                                                    Date

___________________________________________          _________________

Address:________________________________City:___________  Zip:________

Telephone: ______________________________

If not an Oxford Resident: _____________________________________________

Church Affiliation

Please Return Form With Valid Identification For Every Family Member

Access to the USDA Food Program

In the near future the Oxford Food Shelf will have access to the federally funded USDA Food Program.  In order to receive these food items families will need to meet specific eligibility requirements based on the size of each household.

Note: To guarantee confidentiality family names are not reported.

Please x mark every program from which you receive any services

 PROGRAMS:   __ Food Stamps  __ WIC  __ School Breakfast __ School Lunch  

   __ Welfare __ Fuel Assistance __ Veteran’s Aid __ Head Start

 __ TAFDC  __ Medicade  __ None

 INCOME:        __ Employment __ Unemployment __ SSI __ TANF __ EADC

                          __ Other__ None

Please x indicate your income level based on the chart below.

Yes  No   #  In Household                          Annual         Monthly    Weekly

__ __ 1  Does Household Income Exceed   $20,036       $1,670       $   386   

__   __  2  Does Household Income Exceed   $26,955       $2,247       $   519

__   __  3  Does Household Income Exceed   $33,874       $2,823       $   652

__   __  4  Does Household Income Exceed   $40,793       $3,400       $   785

__   __  5  Does Household Income Exceed    $47,712       $3,976       $   918

__   __  6  Does Household Income Exceed    $54,631       $4,553       $1,051

__   __  7  Does Household Income Exceed    $61,550       $5,130       $1,184

__   __  8  Does Household Income Exceed    $68,469       $5,706       $1,317

__   __  9  Does Household Income Exceed    $75,388       $6,282       $1,452

__   __ 10  Does Household Income Exceed    $82,307       $6,859       $1,586

__   __ 11  Does Household Income Exceed    $89,226       $7,436       $1,719

__   __ 12  Does Household Income Exceed    $96,145       $8,012       $1,852

__   __ 13  Does Household Income Exceed $103,064        $8,589       $1,985

   __      I do not want to participate in the USDA Food Program

Definitions: TANF = Temporary Assistance for Needy Families

                     TAFD = Transitional Aid to Families with Dependent Children

      EADC or EAEDC = Emergency Aid to the Elderly, Disabled & Children

 ID#_______   Name: ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_____________________________________________

 Address:  ____________________________________________________