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USDA Proxy form for students to receive a food kit

*This form is currently incomplete, but you may preview it below.

Please read the following statement carefully, complete the requested information and sign below to receive food from this distribution:

By signing this form, I declare that I am either:

  1. In need of emergency food or
  2. A participant in an income based program such as WIC, CSFP, cash assistance (FIP) or food stamps (FAP) OR
  3. In a household where the income falls at or below the posted federal poverty guidelines (see table below)
  4. Students listed below have my permission to receive a backpack that may contain USDA food products.

Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.  Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits.  Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.  Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter 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;

(2)  fax: (202) 690-7442; or

(3)  email: program.intake@usda.gov

This institution is an equal opportunity provider.

Revised:6-13-17