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Food Pantry Form


Household Member 1

Household Member 2

Household Member 3

Household Member 4

Household Member 5

Household Member 6

Household Member 7


Thank you! We’ll be in touch.

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-8. 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

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-
3027) found online at: How to File a Complaint, and at any USDA office, or write a letter addressed to USDA.

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