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�, .`,rte.r` }^ t:: •;:• '.!•: ,•f. ! a-; •,�. , <br /> . . , 01 <br /> SURPLUS CHEESE AND BMW. APPLICATION <br /> r" <br /> I, the undersigned, declare that I am eligible to receive cheese and/or butter <br /> based on the full criteria: <br /> I an 60 years of age or older. <br /> I am disabled and receive Social Security Benefits and/or SSI. <br /> I receive Food Stamps, AFDC and/or Braid: <br /> My family's gross mcnt 1y income is at or below the amount listed <br /> for my family size. <br /> . <br /> Family Size Griss Monthly Income Family Size Gross Monthly Income <br /> 1 ' $ 585 5 $1,355 <br /> 2 778 .6 1,548 <br /> 3 970 7 1,740 <br /> 4 1,163 Add $193 for each additional family <br /> member. <br /> There are members of my family. <br /> Name: <br /> Sigriatur' of Applicant Date <br /> Andres s: <br /> County <br /> I <br /> STOP: The ,remainder of this form is to be !•feted • the Distribu • Official. <br /> I <br /> 1. Distribution: 2. Date Issued <br /> Blocks of cheese (5 lbs. per block) <br /> Blocks of butter (1 ib. per block) <br /> i. <br />