Letter of Proxy*

Date

(First and Last Name of Client)______________________

(Client’s Address)_____________________________

(Client’s City), (Client’s State)   (Client’s Zip) _____________________

(Client’s Phone Number)______________________________

Number of People in Household by age:

Age 60+: ____                Age 18 – 59: ____                Age birth – 17 :____                Total:  ____

To:  Bulldog Bags, Inc.

From:  (First and Last Name of Client)_______________________________

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 Name) ___________________________

(Proxy Complete Address) _____________________________

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.  Thank you for your assistance.

Sincerely,

(Signature of Client) ____________________________

(Date Signed)_______________________________

*MUST BE UPDATE ANNUALLY AND/OR IF HOUSEHOLD COMPOSITION CHANGES