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2. The Emergency Food Assistance Program (TEFAP) commodity food is distributed on a monthly basis to qualified low-income Livonia residents based on their total household income and residency. Residents who receive SSI, Bridge Card or Medicaid benefits are automatically eligible. Those receiving all other sources of income must qualify based on federal income guidelines.
4. In order to be eligible for the program you must meet the eligibility guidelines and submit an application along with proof of income and Livonia residency. For further information, please call (734) 421-6450 ext. 105
6. • proof of Livonia residency such as your driver’s license or state ID
7. • proof of monthly income such as a pay stub or social security income statement
9. General Information
11. First Name*
12. Middle Initial
13. Last Name*
15. Address*
16. Apt #
17. Zip Code*
19. Birthdate*
20. Phone Number*
21. Email Address*
23. Preferred Method of Contact*

    1. Email
    2. Phone
25. Household Members
27. Full Name
28. Relationship
29. Date of Birth
30. Age
32. Full Name
33. Relationship
34. Date of Birth
35. Age
37. Full Name
38. Relationship
39. Date of Birth
40. Age
42. Full Name
43. Relationship
44. Date of Birth
45. Age
47. Full Name
48. Relationship
49. Date of Birth
50. Age
52. Full Name
53. Relationship
54. Date of Birth
55. Age
57. Full Name
58. Relationship
59. Date of Birth
60. Age
62. Full Name
63. Relationship
64. Date of Birth
65. Age
67. Housing Type*

    1. Mobile Home
    2. Evacuee
    3. Student Housing
    4. Own Home
    5. Youth Home/Shelter
    6. Senior Living Facility
    7. Private Rental
    8. Public Social Housing
    9. Emergency Shelter
    10. With Family/Friends (Permanent)
    11. With Family/Friends (Temporary)
68. Assistance Received*

    1. AFDC
    2. Aid to the Blind or Disabled
    3. Bridge Card/SNAP
    4. Energy Assistance
    5. WIC
    6. Temporary Assistance to Needy Families
    7. Vet's Aid
    8. CSFP - Commodity Supplemental Food Program
    9. Children's Health Insurance Plan (CHIP)
    10. Family Independence
    11. FAP
    12. Headstart
    13. Housing Voucher Choice Program (HVCP)
    14. Medicaid
    15. School Meals (Free or Reduced Lunch)
70. Income
72. List all income for everyone in the household. (Example: Social Security, Pension, Unemployment Benefits, Wages, SSI, SSD, Child Support, Income from Rental Property, Land Contracts, Self-Employment, Etc.)
74. Household Member
75. Source of Income
76. Monthly Amount
78. Household Member
79. Source of Income
80. Monthly Amount
82. Household Member
83. Source of Income
84. Monthly Amount
86. Household Member
87. Source of Income
88. Monthly Amount
90. Do you need help with a Utility Shut-off Notice?*

    1. Yes
    2. No
92. The City of Livonia Housing Commission provides eligible low/moderate income residents with utility (gas, electric, or fuel heating) shut-off assistance when a “SHUT-OFF” notice has been received from the utility company.
94. • Up to $500 may be available to those who meet eligibility requirements
96. • Funds are given on a ONE-TIME only basis
98. • Applicant must be occupant at the address of the shut-off/disconnect notice with utility service in their name
100. • Income limitations and other restrictions apply
102. Are you interested in receiving mental health counseling services?*

     1. Yes
     2. No
104. We also provide financial assistance to income eligible Livonia residents to obtain professional mental health counseling services. The financial assistance provided is as follows:
106. • $400 in assistance per year, per eligible family/household
108. • $80 per counseling session
110. • A minimal Co-Pay, based on income, will be required per visit
112. How did you hear about us?*

     1. Family
     2. Friend
     3. City Website/Newsletter
     4. Livonia Cares
     5. Other
114. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
116. Electronic Signature
Leave This Blank:


118. 1. Receive an email copy of this form.
119. Email address

     This field is not part of the form submission.

120. Submit

* indicates a required field