Food Pantry Intake


Head of Household







Living in Household (children & adults)




Income Verification * (all members in household)

This table shows a yearly gross income for each family size. If your household is at or below the income listed for the number of people in your household, you are eligible to receive food.

Household Size Annual Monthly
1 $25,520 $2,127
2 $34,480 $2,873
3 $43,440 $3,620
4 $52,400 $4,367
5 $61,360 $5,113
6 $70,320 $5,860
Each Additional add $8,960 $746

Statement of Service: As a client of these services you are not required to receive SNAP, WIC, HEAP, Unemployment, Disability, SSI, or TANF or any other program to receive assistance. You will not be turned away on your first visit because of a lack of identification, lack of referral or inability to prove address.
To assist all of those in need, this Food Bank partner may limit the services they provide to a defined area and number of times per month you may return.
Questions maybe directed to Food Bank of Central New York, Agency Relations Department by calling 315-437-1899.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form.
To request a copy of the complaint form, call (866) 632-9992.
Submit your completed form or letter to USDA by: Policy Memorandum No. FD-036 Page 6
(1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington D.C. 20250-9410; or
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov
This institution is an equal opportunity provider.


I certify that my yearly gross household income is at or below the income listed on this form for households with the same number of people as my household, OR that my household participates in the program that I have checked on this form. I also certify that, as of today, my household lives in the area served by the Emergency Food Assistance Program. This certification form is being completed in connection with the receipt of Federal assistance. Per State policy, program officials may verify what I have certified to be true. I understand that making a false statement may result in having to pay the State for the value of the food improperly issued to me and may subject me to criminal prosecution under State and Federal law.

Additional services are available such as Home and Educational support.

YesNo

Head of Household



Living in Household (children & adults)





Youth Program's Emergency & Notification




All children who come to JCTOD Outreach, Inc. - dba Johnson Park Center (JPC) - Youth Enrichment Drop-In Center and Playground are served on a first come, first served basis. JPC is not responsible or maintaining a slot on any particular day for any particular child; and has no responsibility for monitoring the child's attendance, arrival and/or departure from the JPC Youth Enrichment Drop-In Center and Playground. Formal written program policies are available to be read upon request. My child/children have the permission to attend the JPC Youth Enrichment Drop-In Center and Playground. By signing this form, I consent to my child/children's to participate. I understand that participation is on a volunteer basis, and I will not hold JPC liable should any injury occur, personal belongings damaged-lost through the programs and all participants or on any of JCTOD Properties. I agree and give permission a) that my child/children's medical/health needs are made known in writing of this document. b) Written, visual and/or acoustic recordings etc. at/through JCTOD will be the property of the Agency and can be used in various forms in internal and external PR/media coverage. I also attest that my family is low/moderate income by means of this document.