Neighbors Serving Neighbors Self Certification Form

By signing above , I certify that:

1. I am a member of the above household living at the address provided and I apply for USDA Foods that are distributed through The Emergency Food Assistance Program;

2. All information provided to the agency determining my eligibility is, to the best of my knowledge and belief, true and correct; and

3. If applicable, the information provided by the proxy is, to the best of my knowledge and belief, true and correct.