TEFAP Form - River Valley Regional Food Bank

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- Learn About Hunger
- Hunger in America
Get Involved
Get Help
- Pantry Locator
- Additional Assistance
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TEFAP Form

TEFAP FormJulie Moncrief2025-03-24T12:57:21-05:00

Fill out the form below online, or print and mail this form.

TEFAP USDA Foods Certification Application

Name(Required)

First Last

Address(Required)

Street Address Apartment # (if applicable) City State ZIP Code

County(Required)

Phone

Email

Date of Birth

MM slash DD slash YYYY

I understand to receive USDA food from either the TEFAP and/or CSFP food programs that I am required to provide Identification and proof of residency.

Yes

No

I understand to receive USDA food from either the TEFAP and/or CSFP food programs that I am required to accurately declare my household income and household size to determine eligibility in these programs

Yes

No

I understand that to declare and/or provide ANY additional personal information is strictly voluntary and not a requirement to receive USDA foods.

Yes

No

I consent to provide this additional information outside of the Program requirements.

Yes

No

Client Electronic Signature

Date

MM slash DD slash YYYY

Service Insight Coordinator Signature

Date

MM slash DD slash YYYY

EFO Affiliation

HEAD OF HOUSEHOLD INFORMATION

Head of Household

SAME AS ABOVE

Name

First Last

Phone

Email

Date of Birth

MM slash DD slash YYYY

Address

Street Address Apartment # (if applicable) City State / Province / Region ZIP / Postal Code

County

Gender

Male

Female

Employment

Full time

Part time

Unemployed

Marital Status

Single

Married

Divorced

Widowed

Living

Homeless

Disabled

AT RISK of becoming homeless

Education

Ethnicity

Expenses(Required)

Check all that apply

Rent/Mortgage

Utilities

Phone

Average Monthly Expenses(Required)

Government Benefits Received

Check all that apply

Food Stamps (SNAP)

Medicaid

Medicare

Social Security

Veterans Benefits

WIC

OTHER

Income- Type(Required)

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

Income- Monthly amount(Required)

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

Do you have more income to add?

Yes

No

Income- Type

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

Income- Monthly amount

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

Income- Type

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

Income- Monthly amount

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

Income- Type

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

Income- Monthly amount

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

Income- Type

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

Income- Monthly amount

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

Income- Type

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

Income- Monthly amount

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

Income- Type

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

Income- Monthly amount

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

Income- Type

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

Income- Monthly amount

Examples: Social Security, VA Benefits, Retirement, SSI, Workman’s Comp, Disability, Child Support, Employment Wages, Family, Support, Other

HOUSEHOLD MEMBER INFORMATION

Member 1 Name

First Last

Gender

Male

Female

Date of Birth

MM slash DD slash YYYY

Ethnicity

Relation to Head of Household

Member 2 Name

First Last

Gender

Male

Female

Date of Birth

MM slash DD slash YYYY

Ethnicity

Relation to Head of Household

Member 3 Name

First Last

Gender

Male

Female

Date of Birth

MM slash DD slash YYYY

Ethnicity

Relation to Head of Household

Member 4 Name

First Last

Gender

Male

Female

Date of Birth

MM slash DD slash YYYY

Ethnicity

Relation to Head of Household

Member 5 Name

First Last

Gender

Male

Female

Date of Birth

MM slash DD slash YYYY

Ethnicity

Relation to Head of Household

PROXY INFORMATION

These are the people who are allowed to pickup your food in your absence.

Authorized to pick up/proxy NAME 1

Date

MM slash DD slash YYYY

Authorized to pick up/proxy NAME 2

Date

MM slash DD slash YYYY

Authorized to pick up/proxy NAME 2

Date

MM slash DD slash YYYY

Comments

This field is for validation purposes and should be left unchanged.

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