Usda Declaration And Signature Form
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1Number of People in
Self-declaration of Need and Liability Release
Household
Annual
Monthly
Weekly
Pantry Site:
1
$23,760
$1,980
$457
Date:
2
$32,040
$2,670
$613
By signing this form, I declare that I am either: 1) In need of
3
$40,320
$3,360
$775
emergency food or 2) a participant in a USDA income based
program such as WIC, CSFP, or the Food Assistance Pro-
4
$48,600
$4,050
$935
gram (formerly known as “food stamps”) or 3) in a household
5
$56,880
$4,740
$1,094
where the income falls at or below the posted Federal Poverty
6
$65,160
$5,430
$1,253
Level. The food I receive today from ________________ will
7
$73,460
$6,122
$1,413
be used by me and/or my household and will not be sold or
misused in any way. The food I receive today comes from a
8
$81,780
$6,815
$1,573
variety of sources. I
For each additional family
accept the food “as is” and release both the original donor and
member add
$8,320
$693
$160
the pantry from any liabilities, damages, losses, claims,
causes or actions and suits of law pertaining to the food I receive.
Check here if this is your first time accessing USDA
Emergency Food at any location this month
Print Name
Signature
Street Address
City/Township
HH
Size X
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race,
color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental
status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in
employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or em-
ployment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint
Form, found online at , or at any USDA office, or call (866) 632-9992 to request the form. You
may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S.
Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-
7442 or email at program.intake@usda.gov.
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or
(800) 845-6136 (Spanish).
USDA is an equal opportunity provider and employer.”
Revised 4/6/2016
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