Important Forms -

If you would like us to e-mail you one of the forms described below, e-mail your request to: murphysborofoodpantry@gmail.com (or use the contact tab and send us a request specifying which form you would like).   You may also call us at 684-8258 and give us the e-mail address where you would like to receive the form and we'll be happy to e-mail the form to you.  You may also pick up either of the forms mentioned below at the Food Pantry during our regular hours of Monday through Friday from 9:00 a.m. to 11: 00 a.m.

                                

PROXY FORM:

     This form may be filled out by the client to allow another person to pick up their food for them.  A new form is required at each visit.  When using the form, the proxy (person picking up food for the client) must bring BOTH the client's picture I.D. and their own picture I.D.

MINISTERIAL ALLIANCE FORM:

The Food Pantry does not distribute monetary assistance in any form - we only distribute food to qualifying clients. However, if you are a resident of Murphysboro, the Murphysboro Ministerial Alliance does, in some circumstances, attempt to assist with certain emergency situations.

 Note that the form must be mailed to their address given (do not bring it to the Food Pantry since we have no input in this process). Also note that it might take 7 to 10 days to hear back from the Ministerial Alliance - be sure to leave a working phone number where they can contact you when filling out the 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: program.intake@usda.gov.

This institution is an equal opportunity provider.