Cimarron Food Delivery Request Form

Please fill out this form to request a food delivery. We ask for households to do either deliveries or in person. This form is for Cimarron resident use only. Once we receive your request, we will coordinate a delivery to your home in coordination with the Cimarron free food distribution events. Please submit your requests by Friday at 9:00 a.m. for Monday delivery.

Deliveries will occur twice a month on Mondays between 3:30-5:00 pm. Upcoming dates are:

May 8 and May 22
June 12 and June 26
July 10 and July 24
August 14 and August 28
September 11 and September 25
October 9 and October 23
November 6 and November 20

If you would like deliveries on a different date, please submit a request to: https://form.jotform.com/221016367878159

Contact foodshelfdeliverymn@gmail.com or 651-390-6507 with questions.

Name*

First NameLast Name

Enter an Address*

Delivery instructions: Is there a gate or access number needed to enter?

Phone Number*

Alternate Phone Number

Email

example@example.com

How often would you like a delivery? Please note: your order must be received by 9 a.m. the Friday before the delivery.*

One timeEvery other week

Please indicate if you prefer a specific dietary option

Gluten FreeVegetarianVegan

How many people in your household are children (ages 0-17)?*

How many people in your household are adults (ages 18-64)?*

How many people in your household are seniors (age 65+)?*

In compliance with the state’s TEFAP program, eligibility guidelines are posted here and the data privacy statement is here.

By submitting this form, I verify that I am eligible to receive TEFAP commodity food because:
• I am in Minnesota
• My household income is 300% or less of the Federal Poverty Guidelines.
• I am also eligible if I receive or participate in the following services or programs:

MFIP (Minnesota Family Investment Program)
Child Care Assistance, GA (General Assistance)
SNAP (Supplemental Nutritional Assistance Program)
NAPS (Nutritional Assistance Program for Seniors)
WIC (Women, Infants, and Children)
Head Start
Section 8
Public Housing
Energy Assistance

Please call 651-390-6507 or email info@eastmetrofooddelivery.org with any questions.

By submitting this form, I understand that I am voluntarily providing private information about myself. I understand I am not required to provide this data but if I do not I will not be able to have essential goods delivered to me. I understand and agree my data may be shared with providers of delivery of essential goods, persons that I give written consent and as required or authorized by law.