Emergency Food Distribution Network EFDN Request Form Preferred language*EnglishSpanishVietnameseOtherZip* 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 NoAge Group*18-3435-5555-6465 and upNumber of individuals in your household*123456789101112131415Number of individuals 18 or younger in your household0123456789101112131415Number of families in your household*12345RaceCaucasian/EuropeanBlack/AfricanHispanicOther/MixedAsian/Pacific IslanderNative AmericanAleut/HawaiianMiddle EasternEthnicityNon-Hispanic / Non-LatinoHispanic / LatinoGender*MaleFemaleOtherMarital StatusSingleMarriedSingle ParentCohabitingVeteran Yes NoDisabled Yes NoHomeless Yes NoActive Military or Dependant Yes NoPreferred method for confirmation of your requestTextEmailPhoneHiddenWere 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 NoIf No, what is the reason you cannot pickup your food?*No Transportation - I do not own a vehicleHomebound – High Risk (Enter detail in note)Unable to drive (Enter detail in note)Please provide detailsIf 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 OtherDisclaimer* 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.HiddenDate Month Day YearHiddenTime : AMPM AM/PM You need javascript enabled to view this content or go to source URL.