1. No category

must not
based on
Summer Weekend Meals and Mobile Farmers’ Market Application
Please complete the questions below for the Summer Food Program.
Name of Applicant:
Current Address:
Name of Child(ren):
Telephone Number Where You Can Be
Reached:
(
1.
)
Are you currently receiving cash or food assistance from a job and family services department?
Please circle the correct response:
Yes
No
If yes, please give the county JFS, they type of assistance received, and the date received below:
County JFS:
2.
Type of Assistance: Cash or Food
(Circle all that apply)
If you are not currently receiving cash or food assistance in Ohio, is your household is within 200% of Federal
Circle
Poverty Level?
Please circle the correct response:
Yes
No
3. By signing this application you verifying that you have granted approval for your child(ren)’s participation in this
program and verify that the above answers are correct.
_____________________________________________________________
Parent or Legal Custodian Signature
Family Size
Federal Poverty
200%*
For StaffGuidance
Use:
1
2
3
4
5
6
7
8
9
10
11
12
$1,962
$2,655
Application Approved
$3,349
Application Denied
$4,042
$4,735
$5,429
$6,122
Name of Staff processing form:
$6,815
______________________________________________________________________
$7,509
$8,202
$8,895
$9,589
Date:_________________________
_________________
Date