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Get TX CAFB Food Pantry Intake Form

Food Pantry Intake Form All CAFB Partner Agencies are required to use this intake form Name Address City State Zip Code Phone Number Number of People in Household Are you currently receiving any form of government assistance ie Food Stamps Social Security etc. Receiving government assistance is an income eligibility indicator allowing food pantry staff to know you automatically are eligible to receive USDA commodities. Yes No Client Signature Date NOTICE TO CLIENTS If you receive food from this emergency pantry please note the following This emergency food pantry is a Partner Agency of the Capital Area Food Bank CAFB and as such has agreed to follow CAFB policies and procedures and Internal Revenue Service IRS regulations regarding distribution of donated goods. This pantry CANNOT Charge a fee or accept monetary donations for food and non-food items you receive. Food Pantry Intake Form All CAFB Partner Agencies are required to use this intake form Name Address City State Zip Code Phone Number Number of People in Household Are you currently receiving any form of government assistance ie Food Stamps Social Security etc* Receiving government assistance is an income eligibility indicator allowing food pantry staff to know you automatically are eligible to receive USDA commodities. Yes No Client Signature Date NOTICE TO CLIENTS If you receive food from this emergency pantry please note the following This emergency food pantry is a Partner Agency of the Capital Area Food Bank CAFB and as such has agreed to follow CAFB policies and procedures and Internal Revenue Service IRS regulations regarding distribution of donated goods. This pantry CANNOT Charge a fee or accept monetary donations for food and non-food items you receive. Require you to provide a service participate in a religious event or join any part of this organization as a condition of receiving food. Refuse assistance to you based on race color age religion national origin disability gender sexual orientation or political affiliation* This pantry must implement guidelines and post them where clients can see them stating any limitations that would affect service stating the following Pantry days and hours of operation* How often your household may visit this pantry. Form of identification if any necessary to receive food. Any service area restrictions Example serves only specific zip code or school boundary. Refuse service to individuals posing a health hazard been verbally or physically abusive or have threatened harm to volunteers staff or other clients. Pantry guidelines MUST be clearly posted* 8201 S* Congress Ave. Austin TX 78745 ph 512. 282. 2111 fx 512. Food Pantry Intake Form All CAFB Partner Agencies are required to use this intake form Name Address City State Zip Code Phone Number Number of People in Household Are you currently receiving any form of government assistance ie Food Stamps Social Security etc* Receiving government assistance is an income eligibility indicator allowing food pantry staff to know you automatically are eligible to receive USDA commodities. Yes No Client Signature Date NOTICE TO CLIENTS If you receive food from this emergency pantry please note the following This emergency food pantry is a Partner Agency of the Capital Area Food Bank CAFB and as such has agreed to follow CAFB policies and procedures and Internal Revenue Service IRS regulations regarding distribution of donated goods. .

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