CSFP Proxy Form
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: firstname.lastname@example.org.
This institution is an equal opportunity provider.
This form's purpose is to allow current pantry clients to designate an individual to pick up their monthly pantry distribution on their behalf. The proxy will be required to show I.D. to confirm for our records.
The easiest route is to print off and have the proxy bring the form with them to pick up your distribution, please download the following form and sign ahead of your distribution date:
Fill out the form and a staff member from GWCFB will call to confirm the proxy request prior to your distribution date.
If you are within 48 hours of your scheduled distribution, we strongly recommend printing the form and having you proxy show the completed form at the distribution.