FDP - Authorized Representative

Authorized Representative

Food & Nutrition Services - Food Distribution Program - CSFP / FDPIR
721 SE 3rd, Suite D
Pendleton, OR 97801
541-276-1926 | 800-752-1139

Serving Gilliam, Hood River, Morrow, Sherman, Umatilla, Wasco, and Wheeler counties
All fields marked with an asterisk (*) are required.
Name*

First Name Last Name
Email
example@example.com
I, {name12}, would like to add an Authorized Representative to pick up my commodities in my absence. I understand that the person I choose may be allowed to make food choices for me, and that CAPECO or any of CAPECO’s employees are not responsible for the choices my Authorized Representative makes on my behalf. I also understand that, with written notice, I have the right to change or discontinue having an Authorized Representative.
The following Authorized Representative is to be*

AddedRemoved
Name*

First Name Last Name
Phone Number (Place an 'x' in appropriate box)*
This is*

OngoingOne time only
For this program*

CSFPFDPIR
Client Signature*

Clear
Date

MonthDay Year
Date
Nondiscrimination Statement:

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at:

http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
1. Mail: U.S. Department of Agriculture
  Office of the Assistant Secretary for Civil Rights
  1400 Independence Avenue, SW
  Washington, D.C. 20250-9410;
2. Fax: (202) 690-7442; or
3. Email: program.intake@usda.gov.
This institution is an equal opportunity provider.
Should be Empty: