Form HRP-1040A "Annual Usda Commodity Food Service Application and Agreement Between Regional Food Bank and Distribution Site" - Arizona

What Is Form HRP-1040A?

This is a legal form that was released by the Arizona Department of Economic Security - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2019;
  • The latest edition provided by the Arizona Department of Economic Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HRP-1040A by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1040A FORPDF (4-19)
Page 1 of 4
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
ANNUAL USDA COMMODITY FOOD SERVICE APPLICATION AND AGREEMENT
BETWEEN REGIONAL FOOD BANK AND DISTRIBUTION SITE – FFY
TEFAP
CSFP
SITE INFORMATION
AGENCY NAME
CONTACT PERSON
MAILING ADDRESS (No., Street)
CITY
STATE
ZIP CODE
DISTRIBUTION ADDRESS (No., Street)
CITY
STATE
ZIP CODE
PHONE NO.
FAX NO.
EMAIL
ELIGIBILITY INFORMATION
Note: A copy of your IRS determination letter must be attached and submitted with this form.
Applicant is a (check all that apply):
Nonprofit Organization
Public Institution
Faith-Based Organization
Provides Food Assistance to needy persons for household
Provides Food Assistance to needy persons in the form of prepared meals
Is not a Penal Institution or Correctional Institution which conducts Rehabilitation Programs
OPERATIONAL INFORMATION
Days and hours of operation per week:
Average number of households in need of food per week: 
Number of food boxes provided during the past calendar year: 
Total number of meals provided during the past calendar year: 
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.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities 
Act  of  1990  (ADA),  Section  504  of  the  Rehabilitation Act  of  1973,  the Age  Discrimination Act  of  1975,  and Title  II  of  the  Genetic  Information 
Nondiscrimination Act  (GINA)  of  2008;  the  Department  prohibits  discrimination  in  admissions,  programs,  services,  activities,  or  employment 
based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this document in alternative format or for 
further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available 
upon request.
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1040A FORPDF (4-19)
Page 1 of 4
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
ANNUAL USDA COMMODITY FOOD SERVICE APPLICATION AND AGREEMENT
BETWEEN REGIONAL FOOD BANK AND DISTRIBUTION SITE – FFY
TEFAP
CSFP
SITE INFORMATION
AGENCY NAME
CONTACT PERSON
MAILING ADDRESS (No., Street)
CITY
STATE
ZIP CODE
DISTRIBUTION ADDRESS (No., Street)
CITY
STATE
ZIP CODE
PHONE NO.
FAX NO.
EMAIL
ELIGIBILITY INFORMATION
Note: A copy of your IRS determination letter must be attached and submitted with this form.
Applicant is a (check all that apply):
Nonprofit Organization
Public Institution
Faith-Based Organization
Provides Food Assistance to needy persons for household
Provides Food Assistance to needy persons in the form of prepared meals
Is not a Penal Institution or Correctional Institution which conducts Rehabilitation Programs
OPERATIONAL INFORMATION
Days and hours of operation per week:
Average number of households in need of food per week: 
Number of food boxes provided during the past calendar year: 
Total number of meals provided during the past calendar year: 
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.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities 
Act  of  1990  (ADA),  Section  504  of  the  Rehabilitation Act  of  1973,  the Age  Discrimination Act  of  1975,  and Title  II  of  the  Genetic  Information 
Nondiscrimination Act  (GINA)  of  2008;  the  Department  prohibits  discrimination  in  admissions,  programs,  services,  activities,  or  employment 
based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this document in alternative format or for 
further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available 
upon request.
HRP-1040A FORPDF (4-19)
Page 2 of 4
PROGRAM REQUIREMENTS OF THE APPLICANT AGENCY: The Applicant Agency  (Distribution  Site)  agrees  that  for  each 
site listed on the site sheet of the application, it shall use United States Department of Agriculture (USDA)
TEFAP
CSFP
commodities  in  accordance  with  USDA regulations  contained  in  7  CFR  Parts  247,  250,  251,  253,  and  254  and  the  Arizona 
Departments of Economic Security (ADES) policies and procedures and shall conform to the following requirements:
1.  Provide
TEFAP commodities  free-of-charge  to  eligible  individuals.  Eligible  individuals  are  low-income,  with  incomes  at 
or below 185% of the Federal Poverty Level.  No supporting documentation is required for income eligibility determination.   
Individuals  receiving  commodities  will  self-certify  they  meet  the  income  guidelines  via  their  signature  in  Link2Feed  or  by 
signing their names on the TEFAP Household Distribution Sign-In Sheet.
2.  Provide
CSFP commodities free-of-charge to eligible individuals. Eligible individuals are low-income, with incomes at or 
below  130%  of  the  Federal  Poverty  Level.  No  supporting  documentation  is  required  for  income  eligibility  determination. 
Individuals receiving commodities will self-certify they meet the income guidelines, by signing their name on either the paper 
or electronic CSFP Application for Benefits in Link2Feed.
3.  Current income guidelines for
TEFAP
CSFP must be posted where it is visible to individuals.
4.  Ensure completion of Link2Feed or Household Distribution Sign-in Sheet for 
TEFAP by individuals receiving commodities 
and/or ensure completion of the
CSFP Application for Benefits (paper or electronic) by individuals interested in receiving 
commodities.
5.  Length of residency or intent to remain in a geographic location must not be used as a criterion of eligibility.
6.  Applicant agency will ensure that 
TEFAP food is distributed in fair share proportions per household size.  A household of 
eight individuals should receive proportionally twice that of a household of four.
7.  Ensure that ability to make a financial donation is not a condition for receiving commodities.  Donations cannot be solicited 
from individuals presenting to receive commodities.
8.
TEFAP distribution sites must be open to the general population. Sites that limit participation or attendance to only their
members may not be TEFAP distribution sites.
9.  Proof of household income shall not be required for an individual to receive commodities.  Income eligibility is a self-declaration 
by individuals after reviewing posted current income eligibility guidelines.  The distribution site may require further individuals’
information for use with other programs.  However, the individual shall not by denied food if they refuse to reveal any information 
that is not a requirement of USDA Code of Federal Regulations
10.  If  it  is  determined  that  a  distribution  site  is  collecting  individual’s  social  security  numbers  and/or  requiring  verification  of 
household income this will be cause for the Regional Food Bank (RFB) to terminate the
TEFAP
CSFP agreement
immediately.
11.  Comply  with  the  requirement  of  all  state  and  federal  regulations  regarding  nondiscrimination.  Specifically,  the  program 
applicant hereby agrees that it will comply with Title VI of the Civil Rights Act of 1964 (42 U.S.C. §2000d et seq.), Title IX 
of the Education Amendments of 1972 (20 U.S.C. §1681 et seq.), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 
§794), the Age Discrimination Act of 1975 (42 U.S.C. §6101 et seq.); the Arizona Disability Act, which prohibits discrimination 
on the basis of physical or mental disabilities; all provisions required by the implementing regulations of the Department of 
Agriculture; Department of Justice Enforcement Guidelines, 28 CFR Part 50.3 and 42; and FNS directives and guidelines, 
to  the  effect  that,  no  person  shall,  on  the  grounds  of  race,  color,  national  origin,  sex,  age,  or  disability,  be  excluded  from 
participation in, be denied benefits of, or otherwise be subject to discrimination under any program or activity for which the 
program applicant receives Federal financial assistance from FNS; and hereby gives assurance that it will immediately take 
measures necessary to effectuate this agreement.
12.  All FNS assistance programs must include a public notification system. The purpose of this system is to inform applicants, 
participants,  and  potentially  eligible  persons  of  the  program availability,  program  rights  and  responsibilities,  the  policy  of 
nondiscrimination, and the procedure for filing a complaint.
13.  Basic Elements of Public Notification. The public notification system must include the following three basic elements:
14.  Program Availability. Each State agency, local agency, or other sub-recipient that distributes program benefits and services 
must  take  specific  action  to  inform  applicants,  participants,  and  potentially  eligible  persons  of  their  program  rights  and 
responsibilities and the steps necessary for participation.
15.  Complaint Information. Applicants  and  participants  must  be  advised  at  the  service  delivery  point  of  their  right  to  file  a
complaint, how to file a complaint, and the complaint procedures.
16.  Nondiscrimination Statement. All information materials and sources, including Web sites, used by FNS, State agencies, local 
agencies,  or  other  sub-recipients  to  inform  the  public  about  FNS  programs  must  contain  a  nondiscrimination  statement.
It is not required that the nondiscrimination statement be included on every page of the program information Website. At the 
minimum, the nondiscrimination statement, or a link to it, must be included on the home page of the program information.
17.  Equal  Opportunity  Employer/Program  •  Under  Titles  VI  and  VII  of  the  Civil  Rights  Act  of  1964  (Title  VI  &  VII),  and  the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination 
services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. 
HRP-1040A FORPDF (4-19)
Page 3 of 4
The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service 
or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are 
deaf, a wheelchair accessible location, or enlarged print materials. 
It also means that the Department will take any other reasonable action that allows you to take part in and understand a
program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand 
or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all 
possible. To request this document in alternative format or for further information about this policy, contact 602-542-0303; 
TTY/TDD  Services:  7-1-1.  •  Free  language  assistance  for  DES  services  is  available  upon  request.  “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.
a.  If the material is too small to permit the full statement to be included, the material will at a minimum include the statement, 
in print size no smaller than the text that “This institution is an equal opportunity provider.”
18.  Must have a posted Client Grievance Policy and maintain and report information on discrimination complaints to the
Regional Food Bank if any, and their resolutions.
19.  Food  and  Nutrition  Services  (FNS)  requires  civil  rights  training  for  people  involved  in  all  levels  of  the  administration  of 
programs  that  receive  Federal  financial  assistance.  Staff  and  all  frontline  volunteers,  such  as  individuals  who  regularly 
interact with program applicants and participants or determine eligibility must receive full civil rights training on an annual basis 
as outlined in FNS Instruction 113-1, Section XI.
20.  Post “Justice For All” posters on site directly next to where the commodities are distributed and, for religious organizations 
operating CSFP, provide an individual written notice of beneficiary protections, including the right to be referred to another 
organization, to all applicants at the time that they apply for CSFP benefits.
21.  Store and maintain food to allow for proper ventilation, with commodities stored off the floor and away from walls.
22.  Store and maintain food at proper temperatures to prevent loss.
23.  Ensure proper pest control measures are in place.
24.  Immediately, upon discovery, report theft, loss, infestation or other spoilage of any commodities to the sub-distributing agency.
25.  Conduct monthly inventories and complete and submit necessary reports.
26.  Not request or accept more commodities than can be distributed in three (3) months.
27.  Follow first in-first out inventory practices
No right or interest in this agreement shall be assigned or delegated without the written permission of the other party and the 
concurrence of the Arizona Department of Economic Security (ADES). 
This agreement may be canceled upon (30) days’ notice in writing by either party. Notwithstanding the foregoing, the Regional 
Food Bank may cancel this agreement immediately upon receipt of evidence that the terms hereof have not been complied with 
by the Applicant Agency. 
Applicant Agency  signing  below  certifies  that  the  information provided  herein  is  true  and  correct  to  the  best  of  my  knowledge
and that my facility is in full compliance with all Federal, State, County and Local health codes and ordinances regarding food 
storage.
Agency Representative’s Name (print or type)
Agency Representative’s Title
Agency Representative’s Signature
Date
By signing below, the Regional Food Bank has approved the CSFP USDA Commodity Food Service Application and Agreement as completed.
Regional Food Bank Representative’s Name (print or type)
Regional Food Bank Representative’s Title
Regional Food Bank Representative’s Signature
Date
HRP-1040A FORPDF (4-19)
Page 4 of 4
ASSURANCES
Check to Indicate You Have Read and Understand the Assurance Statement.
TEFAP
CSFP
Each agency receiving USDA Foods for distribution is responsible for any loss resulting from improper distribution, or 
improper storage, care, or handling of USDA Foods.
Each agency receiving program funds is responsible for any misuse of program funds.
The CSFP applicant agency will provide, or cause to be provided, nutrition education to participants once per month as 
an attachement (e.g., a flyer or newsletter) to the distribution.
The CSFP applicant agency will provide information to participants on other health, nutrition, and public assistance 
programs, and make referrals as appropriate.
The CSFP applicant agency will distribute USDA Foods in accordance with the approved food package guide rate.
The CSFP applicant agency will take steps to prevent and detect dual participation.
The CSFPapplicant agency will not subject any person to discrimination under the program on the grounds of race, 
color, national origin, age, sex, or disability.
By signing below, the Agency Representative certifies that they concur with the above assurances.
Agency Representative’s Name (print or type)
Agency Representative’s Title
Agency Representative’s Signature
Date
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