By signing, I certify that:

(1) I am a member of the household living at the address provided and that I apply for USDA Foods that are distributed through The Emergency Food Assistance Program;

(2) all information provided to the agency determining my eligibility is, to the best of my knowledge and belief, true and correct; and

(3) if applicable, the information provided by the proxy is, to the best of my knowledge and belief, true and correct.

The Emergency Food Assistance Program (TEFAP)

Participant Rights and Responsibilities

1. I will not be denied USDA Foods if I am determined eligible.

2. I certify that the information I have provided for eligibility determination is correct to the best of my knowledge.

3. I agree to report changes in household circumstances, including, but not limited to, income and household size.

4. I may appeal any decision made by the food bank or distribution site. I can inform the distribution site or food bank that I want to appeal.

5. I understand that if I choose a proxy to pick up my food, that person must be listed as a proxy either 1) on my Household Application for USDA Foods or 2) on a note with my signature.

6. I understand that the food provided by this program is intended for the members of the eligible household.

7. I understand that I must not sell or exchange USDA Foods.

8. I consent to the release of information to TEFAP staff, which includes officials of United States Department of Agriculture, Texas Department of Agriculture, and the food bank.

9. Program staff have advised me of my rights and responsibilities under this program.

10. I understand that I may request a written copy of TEFAP Written Notice of Beneficiary Rights.

11. I understand that the standards for participation in this program are the same for everyone regardless of race, color, national origin, age, sex, or disability.

12. I have read this form, or the form has been read to me.

13. The distribution site maintains the right to ensure orderly distribution.

In accordance with Federal civil rights law and U.S. 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:, 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 This institution is an equal opportunity provider. (2) fax: (202) 690-7442; or (3) email: