Form Hrp-1026a Forff - The Emergency Food Assistance Program (Tefap) Beneficiary Referral Request

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HRP-1026A FORFF (6-16)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Coordinated Hunger Relief Program
THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP)
BENEFICIARY REFERRAL REQUEST
Organization Informatio
n
NAME OF ORGANIZATION
PROGRAM STAFF MEMBER NAME
ORGANIZATION STAFF MEMBER PHONE
ORGANIZATION STAFF MEMBER EMAIL
NUMBER
ADDRESS
YOUR USE OF THIS FORM IS VOLUNTARY
If you object to receiving services from us based on the religious character of our organization, please complete this form and return
it to the program contact person identified above.
If you object to the religious character of our organization, we must make reasonable efforts to identify and refer you to an alternate
provider to which you have no objection. We cannot guarantee, however, that in every instance, an alternate provider will be
available.
Please check the box if you want to be referred to another service provider.
Alternate Service Provider (ASP) Location Information
TEFAP Locations (online maps)
https://des.az.gov/emergency-food-assistance-program-tefap-locations
Additional Locations (online maps)
ASP Organization Name:
ASP Distribution Address:
ASP Program Contact Phone Number:
ASP Distribution Days/Time
(if known):
Organization Staff Use Only
Date of Objection:
Referral Status:
Client was referred to organization listed above using non-state agency resources.
Client was referred to organization listed above using state agency resources
Client left without a referral.
No alternative service providers were available (summarize on the back of this form the efforts made to identify an alternate
service provider; include contacts made with the state agency or regional food bank).
See reverse for USDA nondiscrimination and EOE/ADA/LEP/GINA statements.

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