Qualifying Reason (Please indicate by check)
A participant in one or more local state or federal programs at or below the income threshold established by the state agency for TEFAP eligibility will automatically qualify for TEFAP USDA Foods.
I am accepting a charitable donation of food from the Emergency Food Pantry. I hereby relinquish the Food Pantry of all liability of any nature whatsoever and accept the food products "as is" and at my own risk.
"I certify that my total yearly gross household income is at or below 185% of the poverty level, OR that my household participates in the program(s) that I have checked on the Emergency Food Registration Form. I will also notify the Pantry, if there are changes to my income or qualifiers which may cause me to become ineligible for the TEFAP USDA foods."
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-0ASCR%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 ог (202) 690-7442; ог
3. email:
program.intake@usda.gov
This institution is an equal opportunity provider. 9/8/2022