Food Box Request Form

Food Box Request Form

Salvation Army Juneau
Full Name*

First NameLast Name
E-mail*
Contact Number*

Area CodePhone Number
Number of Individuals in Household*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Proxy Name (If Needed)
Permanent Fund Dividend: did anyone in your household receive the current year’s PFD? If YES, include the PFD amount received in your Annual Household Income at the time of applying.

The table below shows a yearly gross income for each family size. If your household income is at or below the income listed for the number of people in your household, you are eligible to receive TEFAP donated food. Proof of income is not required to apply for TEFAP.
Household Size - Choose only 1

12345678+
Annual Income - Choose only 1

$50,970$68,670$86,370$104,070$121,770$139,470$157,170$174,870
PROGRAMS BENEFITS: if you currently participate in a program listed below, you are automatically eligible to receive TEFAP and do not need to look at the income scale. Click all that apply (Yes)

Snap (Food Stamps)Tribal TANF/ATAPSSI or MedicaidCSFP or FDPIRNSLP Lunch Free/Reduced
Signature: I certify, under penalty of perjury, that the above information is true and correct to the best of my knowledge and that I am eligible to receive USDA Foods according to current income guidelines

Clear
In accordance with federal civil rights 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 (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, 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. 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-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.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 the 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: mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights,1400 Independence Avenue, SW, Washington, D.C. 20250-9410; or fax:(833) 256-1665 or (202) 690-7442; or email: Program.Intake@usda.gov
This institution is an equal opportunity provider.
MISSION STATEMENT
The Salvation Army, an international movement, is an evangelical part of the universal Christian church. It’s a message is based on the Bible. Its ministry is motivated by the love of God. Its mission is to preach the gospel of Jesus Christ and to meet human needs in His name without discrimination.

FOOD PICK UP - NO DELIVERY!!!
Time: Thursday 4:00pm - 6:00pm
Location: 439 W Willoughby Ave. Juneau, AK 99801

NOTE
Can only sign up for Food Box/Bag every other week (to help as many people as we can)
This is a Pre Sign Up for Food Boxes that will be picked up on Thursdays of the week you signed up for the food Box
All food boxes are prepared

Need to have have the form completed and in by 12:00pm on Wednesday to have food prepared for Thursday Pick Up.

Be Safe – Be Healthy
Should be Empty: