Please read the following statement carefully. If you agree, please check the appropriate response. 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 I have checked on this form. I also certify that, as of today, my household lives in Iowa. This certification form is being completed in connection with the receipt of federal assistance. I understand that once I agree on this form, I am assumed to be eligible for future distributions. I understand that I am required to report to the pantry if my income increases over the income amount listed for my household. 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. *
