USDA Self Declaration

Our intake form is available in the following formats:

the horizontal, 10 line form in English.
Download the individual version, this gives the most privacy for each household. This file contains both an English and a Spanish form.
Download the horizontal, 10 line form in Spanish.

The Self-Declaration of Need form is updated every year. Check the bottom of the form for the date to determine if you are using the current form.

If you need the form in a different format, please contact an Agency Staff member.

Please note, any changes to the form must be approved by the Department of Education for the State of Michigan.