FOOD RECEIPT SIGNATURE FORM

RECIPIENT SIGNATURE FORM

THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP)

NJ STATE FOOD PURCHASE PROGRAM (SFPP)

Agency: The Food Brigade Inc.
Agency ID: A2634-01
The Food Brigade Inc. is an equal opportunity provider.

TEFAP FOODS: Shall not be sold, exchanged or otherwise disposed of without the approval of the New Jersey Department of Agriculture.

YOU MUST SIGN AND SUBMIT THIS FORM EACH TIME YOU RECEIVE FOOD

Date you received food*

Name*

Number of adults in household*

Number of children in household*

Qualifier Code* 1 - TANF Temporary Assistance for Needy Families
2 - SNAP/Food Stamps
3 - SSI Supplemental Security Income (SSI)
4 - WIC Women, Infants, and Children
5 - Medicaid
6 - Low Income
7 - Disaster

Street address*

City/town*

Zip Code*

County of residence*

With my signature I acknowledge that I qualify for and received USDA Commodities from this pantry.*

With my signature I acknowledge that I have received food purchased through the New Jersey State Food Purchase Program.*

Signature (use mouse on computer or finger/stylus on mobile device)*

Prove that you are a human:

RECIPIENT SIGNATURE FORM

THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP)

NJ STATE FOOD PURCHASE PROGRAM (SFPP)

YOU MUST SIGN AND SUBMIT THIS FORM EACH TIME YOU RECEIVE FOOD

Thank you. Your signature has been recorded.

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