THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP) CERTIFICATION OF ELIGIBILITY

Distribution Site Address: 9225 GREENLEAF AVE SANTA FE SPRINGS CA 90670

Contact Name: EDNA LOPEZ        Contact Phone: 408-665-2539

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In accordance with Federal law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability, and reprisal or retaliation for prior civil rights activity. (Not all prohibited bases apply to all programs.)

 

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, and American Sign Language) should contact the responsible State or local Agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

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To file a program discrimination complaint, a complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form, which can be obtained online, at https://www.usda.gov/ sites/default/files/documents/usda-program-discrimination-complaint-form.pdf from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform he Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:

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Mail: U.S. Department of Agriculture                                       Fax:

Office of the Assistance Secretary for Civil Rights                   (833) 256-1665 or (202) 690-7442

1400 Independence Avenue                                                     Email:

SW Washington, D.C. 20250-9410                                            program.intake@usda.gov

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This institution is an equal opportunity provider.

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You self-declare that:

1. Your name and address listed is correct; if homeless, you can put homeless as the address.

2. Your household size as stated and resides within this state and organization’s service area.

3. Your income is within 235% of the Federal Poverty Guidelines as posted for this distribution.

4. You agree that TEFAP food is for home consumption only and will not be sold, traded, or bartered.

5. You have been shown and have read the full USDA Nondiscrimination Statement.

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You will not be denied TEFAP food if you refuse to disclose any information that is not a requirement of TEFAP. You will never need to provide your social security number or proof of income

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