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FOOD PANTRY REGISTRATION - ENGLISH

* Required Fields

Contact Information

First Name

Last Name

Address

Address 2

City

State/Province

Zip/Postal Code

Home Phone

Cell Phone

Work Phone

Date of Birth
(mm/dd/yyyy)

Household Information

List the names and birthdays of all household members.

Do you have any dietary needs
that require special arrangements?

If yes, please explain

Check here if you are a female head of household

Please check Option 1 or Option 2:

OPTION 1: Categorical Eligibility: You are categorically eligible to receive USDA Foods through TEFAP if your household participates in any of the following programs: SNAP, WIC, TANF, Medicaid, or SSI.

OPTION 2: Household Income: If your gross annual household income is at or below the amount listed for the number of people in your household, you are eligible to receive USDA Foods through TEFAP.

If choosing option 2, please select one of the following:

By checking here, you attest that the following is true:

1. The recipient’s name, address (*to the extent practicable) and household size provided above is correct.

2. The recipient resides within New York State (there is no minimum length of residency required).

3. The recipient meets Option 1 or Option 2 of TEFAP eligibility guidelines above.

4. This food is for the recipient’s home consumption only, and will not be sold, traded or bartered.

5. The recipient is aware of their civil rights as described in the USDA Nondiscrimination Statement below.

Recipient Signature (type name here):

Date:

USDA Nondiscrimination Statement:

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508- 0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA.

The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by: 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: (833) 256-1665 or (202) 690-7442; or 3. email: [email protected]

This institution is an equal opportunity provider.

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