YORK

NEW YORK STATE Office of of General Services

The Emergency Food Assistance Program (TEFAP) Attestation of Eligibility

Step 1: Check one of the two boxes below to indicate how you are eligible for TEFAP.

Categorical: You are categorically eligible to receive USDA Foods through TEFAP if your household participates in any of the following programs: SNAP, WIC, TANF, Medicaid, or SSI.

Household Income: If your gross annual household income is at or below 225% of the federal poverty level for the number of people in your household, you are eligible to receive USDA Foods through TEFAP (see appendix A Step 2: Check the box below to attest, then sign and date.

By checking here, you attest that the following is true: 1. The recipient's name, zip code and household size provided above is correct. 2. The recipient resides within New York State (there is no minimum length of residency required 3. The recipient meets the TEFAP eligibility guidelines in step 1. 4. This food is for the recipient's home consumption only, and will not be sold, traded, or bartered. 5. The recipient is aware of their civil rights as described in the USDA Nondiscrimination Statement below.

USDA Nondiscrimination Statement

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%20PComplaint-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: 1. mail: U.S. Department of AgricultureOffice of the Assistant Secretary for Civil Rights1400 Independence Avenue, SW Washington, D.C. 20250-9410; or 2. fax: (833) 256-1665 or (202) 690-7442; or 3. email: program.intake@usda.gov This institution is an equal opportunity provider.

OGS I USDA Food Distribution I (518) 474-5122 https://ogs.ny.gov/usda-food-distribution

Total individuals in household:

Adults (18-59) Toddlers (2-5)Seniors (60+) Please list and provide identification for each person in your household (*use additional sheets if necessary)

You will not be turned away on your first visit because of a lack of identification, lack of referral, or inability to prove address. You will not be asked to provide your Social Security number to receive food. If you are currently homeless or in a transitional/temporary housing situation, please let the staff/volunteer assisting you know that you may not be able to provide a current address. To assist all of those in need, this agency may limit theservices they provide to a defined area and number of times per month you may

Will will not allow pickups without the name here or a written and signed note. Signatures must match.

You will sign in to the weekly sheets for proof of attendance.

Welcome to Evangel Food Pantry a program of Morlock Foundation, Inc. Food pantry text line: 716-221-0218 Calls or text to volunteers to try to get in without an appointment or to try to get food for you is not permitted. BY APPOINTMENT ONLY!!!!! Use the food pantry text line for questions, but remember the line, no matter if you call or text, is only checked Monday thru Wednesday. If you leave a message on Wednesday afternoon, you will not get a response until a clientcare person signs in. FPclientcare@morlockfoundation.org is for questions as well. Checked exactly like textline. The pantry is open on Monday except on special holidays, and self-care days are closed. ALL CLIENTS need to book an APPOINTMENT THROUGH THE CALENDLY LINK; no exceptions. Get a friend, child, or other to help you make sure you have appointments. 2 per month are allowed. We will be serving people by their appointment. If you don't have an appointment, there might be a long time which we cannot tell you how long that will be it is based on number of staff and number of clients. Appointments will help us plan for food, grants, and more. It also protects the client from coming when we are closed, leaving them without all the great food we provide

15 minutes. That is how long we will hold your appointment. If you make an appointment at 9am and show up at 10:30am, you can get an emergency box but will not be served. If you were the last appointment and we have now closed, you can pick up an emergency box in the church office across the parking lot. With a pantry in our location closing, we have a larger number of people. We will not allow people to make appointments and then just not show up or call. Repeated offenders will be offered to attend another pantry. Updates can always be found on the Evangel Food Pantry Facebook page. We partner with the Evangel Assembly of God Church. Please respect their property and their items. Do not take anything unless it is strictly for the food pantry setup. READ all the papers we provide you each time; otherwise, you may be turned away or come when we are closed.

We assign a social worker to each client. They may check in from time to time and would say they are from the Morlock Foundation. If you are needing other help, they will let you know about our Save the Family program and how we can help there; however, that requires different paperwork (it is not mandatory; you must request it Monday appointments DO NOT GUARANTEE drive-thru or walk-in; we may need to switch back and forth based on food availability, deliveries, staffing issues, weather issues, and more. All Food Pantry Appointments link: https://calendly.com/evangelfoodpantry/fp-drive-thru We often hear, "Well I couldn't get the appointment at the time I wanted". That means it is full for that time. You will have to pick a time that is on the calendar.

Please remember there is NO PAID STAFF here and we ask that you treat everyone with respect because if the volunteers quit, then we

can't serve to the best of our ability nor as many as we are serving.

Drive up (Drive thru) to the stop sign (NOT on the Crosswalk, not past the crosswalk) if you are the first person or in the line. Shut your car off and walk inside 1)sign in 2) get your cart and 3)f fill your car. Do not leave anything on the cart or in the parking lot if you do we will have to assume you DO NOT need food and close your registration for the food pantry with us. IF you are not able to walk (example: you have MS, you are disabled, you struggle walking), then please park in the park and text and we will page one of the guys to come fill your car. LIMITED must really be needed because we are limited on staff. We can't be counted on to fill your car. You must be prepared to load your own car with your groceries. Doors are locked at 9:45am to ensure we can get everyone taken care of by 10am. We are closed 10am-10:30am for our lunch break. Clothing will be available most weeks (will be taken care of around 11:30am It will not be available at certain times and the notice will be on the door. Door will close at 9:45am and reopen at 10:30am.10:30am-until serve last appointment is Walk thru. Walk thru during your appointment time only. Shut ins will be served after we serve the last walk thru appointment. Remember, just because you have a walk thru appt doesn't mean you automatically get to walk thru. We will do our best but on occasions you will

be drive thru even after 10:30am.

)Sign in first, take food to car, clothing table comes after 2) Walk thru with the person helping you 3) Put your stuff in your car 4)bring cart back in and leave it at cart door, do not enter the cart door go back to entry door for clothing. We have a lot of people to serve so use of carts is a privilege. Please fill bags as you go around inside and unload quickly and return the cart to the cart door.

We will need to fill other orders so when we serve the last appointment, we close! Allowing us to fill other orders. Eboxes can be picked up in the church office and no extras will be given like breads, meats We will have people working from Sunday afternoon setting up and then from 2am to 3pm or later. Please make sure you attend during your appointment time. 15 minutes means NO SERVICE, ebox only. Enter in door that says enter, not the cart door, not the staff doors. Follow signs and directions.

1. Remember everyone at the food pantry is a volunteer and are here to help you, please treat them with respect. Remember if we aren’t here then you are not here either.  

2. Sign in upon arrival complete the ORS and have a seat and follow instructions

3. You must come in to fill out paperwork once a year, it will vary. You may have another person pickup your food but we must have it in our records otherwise send a note with signature.

4. Updates of income, house size, address change must be put in writing as soon as change has taken effect.  Having it in writing allows us to record it properly.  

5. You are only allowed to attend 1 food pantry.  If you attend more than 1 and it is found out, that is called double dipping and you can be kicked out of both pantries.  We must also notify the foodbank of wny (Feedmore).  

6. We have the use of carts to help you take stuff out to your car.  Carts can not be held on to, so that you can eat, talk, look at clothes or anything else.  We need the carts free to help others.  It is not fair to make others wait.

CARTS CAN NOT BE USED TO OPEN DOORS. You need to go through the door first.  If you break the glass you will be responsible.  

7. You must follow the rules of the shelves and the staff.  If you have 1 person in your family follow the shelves to get only what you are allowed.  Taking extras is considered stealing.  If you have a need to talk to staff about those needs. Do not take church items.

8. There are a lot of people from different religions and cultures,please respect everyone.  

9. All clothing, food and other items given to you at the food pantry are for your use.  You are not allowed to sell them. 

10. We ask for you to let us know if you have other needs you may need help with.  It is important to us that we try to help you with things that are overwhelming.  Please be sure to let us know.  You can call our main office at 842-1300 or text us at 221-0218 or email us at fpclientcare@morlockfoundation.org

11. Fighting is not allowed and your services will be terminated immediately.  

12. No pets are allowed in the church unless they have been cleared for those with handicaps/disabilities ahead of your visit.

13. As you can see others who attend the food pantry, please remember that their participation in the program is not for your discussion to those in the community.  You keep their information private and they will keep yours private.

14.Do not use your cell phone during pantry times so we can assure the privacy of the clients.

15. Our pantry is open on mondays and tuesdays except special holidays or closed dates please make your appt online (keep your appointment time do not come in when you feel like it.)  Appointments are made by using the links provided to you

Walkins close 1 hour  prior to pantry closing times on Tuesdays however drivethru/ parkntext services are still available thru time pantry is open. 

Emergency box pickups must be for emergencies only and cannot be done weekly.  The pick of emergency boxes can be done at the church office Monday-Friday 9:30am-3pm. (unless office is closed for holiday, snow day or other) Times may vary, watch for postings. 

16. Please dress appropriately when coming to the pantry.  Must wear a shirt and shoes. Masks and gloves  if signs state they are required. Follow rules of all signs

17. Please do not come to the pantry under the influence of drugs, alcohol or other. We are mandated to call the police if we see you getting into the driver's seat.  

18. If there is an issue please feel free to let us know right away.  Talk to me, please don’t yell at me.  I can’t help you if you make me upset too. Morlock Foundation Main office 716-842-1300 

19. For Emergencies we call the ambulance it is our policy, NO EXCEPTIONS.

When arriving at the church you are asked to park in the parking spots. OR follow directions for drive thru.  Please do not park in the walkway to come in. Do not park in driveways, parking spots only.

21. Please note, if you come to the door before the time listed above you may not be allowed entry.

22.DO NOT LEAVE CHILDREN OR DISABLED PERSONS, IN CAR WE ARE MANDATED REPORTERS.

I have read and agree to the rules of  Evangel Food Pantry Program of the Morlock Foundation. I will follow the rules and request help when having problems with the rules or do not agree with them.  I will treat everyone with respect. If I do not follow the rules I will be referred to another pantry. 

Appendix A - TEFAP Income Eligibility Table (English) Income guidelines

NEW YORK STATE Income Guidelines

 

For families/households with more than 8 persons, add $12,375 for each additional person

A - TEFAP CORPORATION coffact (Bengali,

A - TEFAP (Traditional Chinese, )

(01/2025) Annexe A - Tableau d'admissibilité au revenu TEFAP (French, Français)

Pour les familles/ménages de plus de 8 personnes, ajoutez 12375$ pour chaque personne supplémentaire

(01/2025) Apendis A - Tablo Kalifikasyon Revni TEFAP (Haitian Creole, Kreyol Ayisyen)

Pou fanmi/kay ki gen plis pase 8 moun, ajoute $12,375 pou chak moun anplis

(01/2025) Allegato A - Tabella di idoneità alle prestazioni TEFAP in base al reddito (Italian, Italiano)

Dimensioni del nucleo familiare

Per famiglie/nuclei familiari di più di 8 persone aggiungere $12.375 per ogni persona in più

(2025/01) Zalacznik A. Kwalifikacja do TEFAP na podstawie dochodu (Polish, polski) Wielkosc gospodarstwa domowego

W przypadku rodzin / gospodarstw domowych liczacych wiecej niz 8 osób nalezy dodac 12375 $ na kazda dodatkowa osobe.

(01/2025) A. Taunnya C B (TEFAP) (Russian, ) Pa3Mep

Apéndice A: Tabla de elegibilidad de ingresos para el TEFAP (Spanish,español) (01/2025)

A. Tabnnya 3 yyacti B (TEFAP) (Ukrainian,

email 7X9 $12,375 IX 02"7 8 U'D 7X9