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

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Required for home deliveries.

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

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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 hardship

Please select the hardship(s) you are currently facing that are impacting your ability to access enough food.

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
COVID-19 Related
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.

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Date

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Time

:

Emergency Food Distribution Network

EFDN Request Form

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WAYS TO HELP

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