Emergency Food Distribution Network

Preferred language*

Zip*

Enter the first 3 or 4 digits and select your zip code from the list.

Other:

Name*

First Last

Email

Phone*

Can we send a text to the phone number you provided*

Yes
No

Age Group*

Number of individuals in your household*

Number of individuals 18 or younger in your household

Number of families in your household*

Race

Ethnicity

Gender*

Marital Status

Veteran

Yes
No

Disabled

Yes
No

Homeless

Yes
No

Active Military or Dependant

Yes
No

Preferred method for confirmation of your request

Hidden

Were you referred by one of the following organizations?

Please select a location from above - IF - you currently receive services or benefits from them.

Are you able to pickup your food when ready?*

Yes
No

If No, what is the reason you cannot pickup your food?*

Please provide details

If we are able to deliver for you, do you have any “additional delivery instructions”:

Food Delivery Address*

Street Address

Certification of COVID-19 hardship*

In order to be eligible, all clients receiving services must have been directly negatively impacted by the COVID-19 pandemic and are unable to access needed services by the Subrecipient Cares Act project. Please select at least one of the following (may select more than one as applicable):

Tested Positive within the last month.
Unemployed-Job loss-laid off-Business closed
Loss of income-reduced work hours-furloughed
Unable to afford food-Food Insecurity
Immunocompromised-At-risk person-Unable to venture outside
Lack of access to equipment for distance learning
Lack of access to affordable childcare services
Mental health impact-Depression-Stress-Anxiety
Other

Disclaimer*

Yes I agree.

BY PARTICIPATING IN THIS FOOD ASSISTANCE PROGRAM, I CERTIFY UNDER PENALTY OF PERJURY THAT MY HOUSEHOLD INCOME DOES NOT EXCEED THE EMERGENCY FOOD ASSISTANCE PROGRAM’S (TEFAP) POSTED MONTHLY GUIDELINES, THAT I AM FACING AN ECONOMIC EMERGENCY, AND THE NUMBER LISTED FOR MY HOUSEHOLD SIZE IS TRUE AND CORRECT. COMMODITIES ARE FOR MY PERSONAL HOME USE, NOT TO BE SOLD, TRADED OR GIVEN AWAY.

Hidden

Date

Hidden

Time

:

EFDN Request Form

POLICIES

CONNECTED

WAYS TO HELP

MEMBER AGENCY OF UNITED WAY * MEMBER AGENCY OF CATHOLIC CHARITIES USA & CALIFORNIA