Commodity-Food Application

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931-896-1800

ADDENDUM ONE: THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP)

Email Address *

Printed Name *

Applicant's Signature

Authorized Proxy's Signature

Number of People in Household *

County *

State/Province *

ZIP / Postal Code *

Is your household's income at or below the limits listed below for the number of people in your household? *If so, you are eligible to receive USDA Foods in TEFAP.YesNo

2024-25 Income Eligibility 185% *The food assistant application – income guidelines$0 - $27,861$27,862 - $37,814$37,815 - $47,767$47,768 - $57,720$57,721 - $67,673$67,674 - $77,626$77,627 - $87,579$87,580 - $97,532More than $97,532

You are also eligible to receive USDA Foods in TEFAP if your household participates in any of the following programs. If you or anyone in your household participates in one of these programs, please check the applicable box. *N/ASNAPFamilies FirstSupplemental Security IncomeLow Income Home Energy Assistance Program, orResidence in Public Housing

I hereby acknowledge having been given the notice of nondiscrimination and Attachment A: Written Notice of Beneficiary Rights for TEFAP as part of this Intake Form.

ADDENDUM ONE: THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP)

INTAKE FORM

NOTICE OF NONDISCRIMINATION:
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/ad-3027.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:

MAIL:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410; or

FAX:
(833) 256-1665 or (202) 690-7442; or

EMAIL:
Program.Intake@usda.gov
This institution is an equal opportunity provider.

ADDENDUM ONE: THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP)

INTAKE FORM

Attachment A: Written Notice of Beneficiary Rights for TEFAP

Name of Organization:

Because TEFAP is supported in whole or in part by financial assistance from the Federal Government, we are required to let you know that:

1. We may not discriminate against you on the basis of religion, a religious belief, a refusal to hold a religious belief, or a refusal to attend or participate in a religious practice.

2. We may not require you to attend or participate in any explicitly religious activities (including activities that involve overt religious content such as worship, religious instruction, or proselytization) that are offered by our organization, and any participation by you in such activities must be purely voluntary.

3. We must separate in time or location any privately funded explicitly religious activities (including activities that involve overt religious content such as worship, religious instruction, or proselytization) from activities supported with direct Federal financial assistance; and

4. You may report violations of these protections, including any denials of services or benefits by an organization, by contacting or filing a written complaint with the

U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights Executive Director Center for Civil
Rights Enforcement
1400 Independence Avenue SW
Washington, DC 20250 9410, or by email to program.intake@usda.gov

5. If you would like to seek information about whether there are any other federally funded organizations that provide these kinds of services in your area, please contact the USDA Hunger Hotline.

The USDA Hunger Hotline:
• By Phone: 1-866-3-HUNGRY or 1-877-8-HAMBRE to speak with a representative from 7:00 AM 10:00 PM Eastern Time.
• By Text: 914-342-7744 with a question that may contain a keyword such as “food” “summer” “meals “etc. to receive an automated response to resources located near an address and/or zip code.

This written notice must be given to you before you enroll in the program or receive services from the program, unless the nature of the service provided, or exigent circumstances make it impracticable to provide such notice before we provide the actual service. In such an instance, this notice must be given to you at the earliest available opportunity.

Save & Finish Later

We're a Community Action Agency serving Clarksville-Montgomery County, created back in 1964 to help fight poverty. We're here to support local families with everyday services and programs that make life a little easier.

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Address: 150 Lafayette Road Clarksville, TN 37042

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