Program Guidelines. 1. The program must be primarily for the general public low income family whose intent is to maintain their pet in their home.

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3 Program Guidelines The primary purpose of this program is to prevent animal surrenders due to a family s inability to feed their pet(s). The following procedures are requested of all DaisyCares Pet Food Program participants (in addition to maintaining the requirements for Agency Partnership 1. The program must be primarily for the general public low income family whose intent is to maintain their pet in their home. 2. Animal Shelters / Rescue organizations may utilize no more than 20 % of all products acquired through the DaisyCares Pet Food Program for internal pet maintenance. 3. Program participants are required to accept referrals from the SAFB and United Way s 211 help line of families in need of pet food assistance. 4. Program participants will be asked to submit monthly reports on pet product distribution to families. (This report will be available online for online submission as well as a hard copy will be provided to all program participants.) 5. Product acquired under the DaisyCares Pet Food Program will be free to program participants (up to quantities dictated by the SAFB). 6. DaisyCares Pet Food Product may NOT be redistributed to any other organization and must be distributed solely by the program participant (interested organizations should contact the SAFB for information on how to participate in the program). 7. DaisyCares Pet Food Product may only be distributed to families who fall under the low income guidelines or families receiving federal benefits such as TANF, WIC, CHIP, MEDICAID, SNAP (Food Stamps), or individuals who are disabled and low income. 8. The SAFB family intake form must be used to qualify families (this form is available on our website) and these intake files should be retained for a minimum of 3 years.

4 Agency Name: Agency Account Number: Program Contact Person Name: Program Contact Person Program Contact Person Phone Number: Families you estimate you can assist with this program? Are you an animal / wildlife affiliated organization? Do you understand that you will have to assist families referred to you by the San Antonio Food Bank as well as the United Way 211 Referral Center? By signing this document you are committing to distribute pet food on behalf of the Daisy Cares Pet Food Program and follow and rules and guidelines of this program, including open service to the community as well as reporting guidelines Signature Date Printed Name: Please fax this agreement to (210) or agreement to

5 Sign-In & Monthly Report The primary purpose of this program is to prevent animal surrenders due to a family s inability to feed their pet(s). The following report is due to Compliance & Capability by the 5th of the month following the distribution month. Family Name # Cats # Dogs # other TOTAL DUE BY THE 5 th OF EVERY MONTH. AVAILABLE ONLINE AT: https://safoodbank.wufoo.com/forms/daisycares-pet-food-program-monthly-report/

6 Page 1 of 2 Please answer all questions so that we may serve you better. This information will not be shared with any other outside agency or entity others than the San Antonio Food Bank for reporting purposes. CLIENT DOCUMENTATION (client may fill this out) Date of Intake: Are you homeless? Yes No If no, please complete address portion of form. Household Information YOUR NAME ADDRESS CITY / STATE/ ZIP/ COUNTY PHONE San Antonio Food Bank Partner Agency Pantry Family Intake Form Form B How many people live in your house: Are you? African American Are you head of the household? Asian Caucasian Hispanic Native American Other How many people live in your house in the following age / gender groups: (please write the number in the box) 0-5 yrs 6-18 yrs yrs yrs 60 and over # Males in house # Females in house How many people live in your house in the following groups: (please write the number in the box) Physically Abuse Mentally People with Chronic Illness Elderly Disabled Victims Disabled Homeless Other: (specify) Military (active, retired or reserve) Does your family receive any type of assistance? Temporary Assistance To Needy Families (TANF / AFDC) SSI CHIP check all that apply SNAP (Food Stamps) Medicaid WIC The Total Gross Income (the amount before deductions) of all household members is: GROSS Per Year Per Month Per Week INCOME $ Was there an emergency situation that caused you to need food? Yes No If yes, please state situation Yes No Client Signature (client must be present for initial interview and food assistance) I certify that I am a member of the household listed above and that on behalf of this household I have applied for USDA Products. I certify that all information regarding my household is true to the best of my knowledge. I also designate the following person as an authorized representative of my household and certify that their information is correct to the best of my knowledge. Authorized representative is able to pick up product for client until re-certification is necessary Date Name of Authorized Representative:(not name of family member only person to act on their behalf) Authorized Representatives Address The U.S Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at or at any USDA office, or call (866) to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , by fax (202) or at Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) ;or (800) (Spanish). Member Agency Guidebook Form B Updated May 23, 2014

7 Page 2 of 2 AGENCY DOCUMENTATION Family Name: Date: Household is INELIGIBLE: (clients denied USDA products should be referred to the SAFB for review) Income level over 185% listed on Annual Income Guidelines Is not an emergency situation and does not meet any other criteria Other: Household is ELIGIBLE based on: Low Income (Enter certification period below; sign and date the form at the bottom) Emergency Food Need (Describe emergency need in Comments section; enter Certification Period; sign and date the form, clients in this category may be served no more than 6 months unless another emergency can be documented.) Receipt of TANF/AFDC (Enter the Certification Period; sign and date the form.) Receipt of Food Stamps (Enter Certification Period; sign and date the form.) Receipt of SSI (Enter the Certification Period; sign and dater the form.) Receipt of Medicaid (Enter the Certification Period; sign and date the form. Certification Period: Start Date: End Date: Comments: Agency Staff Initials: Revisit this form on: Please have client sign every time they come receive assistance (if you have another form for this that is fine, but you must keep all documentation accessible and together) Date Signature of Client (by client) The U.S Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at or at any USDA office, or call (866) to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , by fax (202) or at Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) ;or (800) (Spanish). Member Agency Guidebook Form B Updated May 23, 2014

8 Página 1 de 2 San Antonio Food Bank Formulario de Inscripción para Individuos / Familias Form C Favor de responder a todas las preguntas de manera que podamos servirle mejor. Esta información no será compartida con ninguna otra agencia u entidad otra que el Banco de Comida de San Antonio para razones de reportaje. DOCUMENTACION DEL CLIENTE (el cliente puede llenar este) Fecha de Inscripción: Esta usted sin hogar: Si No Si la respuesta es no, llenar la información de domicilio Su Nombre Su Domicilio Ciudad/Estado/Zip/Condado Teléfono Cuantas personas viven en su hogar: Es usted: Africano- Americano Asiático Anglo- Sajón Es usted cabeza de familia: Hispano Indígena Otro Cuantas personas en su hogar son de las siguientes edades/géneros (favor de poner el número en cada caja) 0-5 años: 6-18 años: años: años: 60 y mayor: # de Hombres en el Hogar # de Mujeres en el Hogar Cuantas personas en su hogar son de las siguientes categorias (favor de poner el número en cada caja) Personas Mayores Sin Hogar Personas Con Discapacidad física Victimas de abuso Personas con discapacidad mental Militares (veteranos, jubilados, activos, reservista) Personas con enfermedades cronicas Otros: (especifique) Su familia recibe alguna forma de asistencia? Si No Si la respuesta es si, indique cuales con una X. Asistencia Temporaria Para Familias Necesitadas (TANF/AFDC) Estampillas de comida SSI Medicaid CHIP WIC Los ingresos totales (antes de deducciones) para todos los miembros del hogar son: Los ingresos totales $ Por año Por Mes Por Semana Hubo alguna situación de emergencia que causo la falta de comida Si No Si la respuesta es si, describa esta situación: Si No Firma de cliente (es necesario que cada cliente este presente la primera vez que reciben asistencia) Fecha Certifico que soy miembro del hogar descrito arriba y como representante de este hogar he aplicado para productos del USDA. Certifico que toda la información tocante a mi hogar es verdadera según mi conocimiento. Designo además la siguiente persona como representante de mi hogar y certifico que su información es correcta según mi conocimiento. El individuo con el firma abajo es responsable de recibir asistencia en nombre del cliente cada distribución hasta la fecha de re-certificación. Nombre de Representante Autorizado Domicilio de Representante Autorizado El Departamento de Agricultura de los Estados Unidos (por sus siglas en inglés USDA ) prohíbe la discriminación contra sus clientes, empleados, y solicitantes de empleo a base de raza, color, origen nacional, edad, discapacidad, sexo, identidad de género, religión, represalias y, según corresponda, convicciones políticas, estado civil, estado familiar o paternal, orientación sexual, o si los ingresos de una persona provienen en su totalidad o en parte de un programa de asistencia pública, o información genética protegida de empleo o de cualquier programa o actividad realizada o financiada por el Departamento. (No todos los criterios prohibidos se aplicarán a todos los programas y/o actividades laborales). Si desea presentar una queja por discriminación del programa de Derechos Civiles, complete el USDA Program Discrimination Complaint Form (formulario de quejas por discriminación del programa del USDA), que puede encontrar en internet en o en cualquier oficina del USDA, o llame al (866) para solicitar el formulario. También puede escribir una carta con toda la información solicitada en el formulario. Envíenos su formulario de queja completo o carta por correo postal a U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , por fax al (202) o por correo electrónico personas sordas, con dificultades auditivas, o con discapacidad del habla que deseen presentar sea una queja de EEO (Igualdad de Oportunidades en el Empleo) o del programa, por favor contacte al USDA por medio del Federal Relay Service (Servicio federal de transmisión) al (800) o (800) (en español). Las personas con discapacidades que deseen presentar una queja del programa, por favor vea la información anterior acerca de cómo contactarnos directamente por correo postal o por correo electrónico. Si necesita medios alternativos de comunicación para obtener información acerca del programa (Braille, caracteres grandes, cinta de audio, etc.) por favor contacte al Centro TARGET del USDA al (202) (voz y TDD).El USDA es un proveedor y empleador que ofrece igualdad de oportunidades. Member Agency Guidebook Form C- Updated May 23, 2014

9 Página 2 de 2 AGENCY DOCUMENTATION (not in Spanish because agency fills out ) Family Name: Date: Household is INELIGIBLE: (clients denied USDA products should be referred to the SAFB for review) Income level over 185% listed on Income Guidelines Is not an emergency situation and does not meet any other criteria Other: Household is ELIGIBLE based on: Low Income (Enter certification period below; sign and date the form at the bottom) Emergency Food Need (Describe emergency need in Comments section; enter Certification Period; sign and date the form. Clients in this category may receive assistance up to 6 months unless another emergency can be documented. ) Receipt of TANF/AFDC (Enter the Certification Period; sign and date the form.) Receipt of Food Stamps (Enter Certification Period; sign and date the form.) Receipt of SSI (Enter the Certification Period; sign and dater the form.) Receipt of Medicaid (Enter the Certification Period; sign and date the form. Certification Period: Start Date: End Date: Comments: Agency Staff Initials: Revisit this form on: Please have client sign every time they come receive assistance (if you have another form for this that is fine, but you must keep all documentation accessible and together) Date Signature of Client (by client) El Departamento de Agricultura de los Estados Unidos (por sus siglas en inglés USDA ) prohíbe la discriminación contra sus clientes, empleados, y solicitantes de empleo a base de raza, color, origen nacional, edad, discapacidad, sexo, identidad de género, religión, represalias y, según corresponda, convicciones políticas, estado civil, estado familiar o paternal, orientación sexual, o si los ingresos de una persona provienen en su totalidad o en parte de un programa de asistencia pública, o información genética protegida de empleo o de cualquier programa o actividad realizada o financiada por el Departamento. (No todos los criterios prohibidos se aplicarán a todos los programas y/o actividades laborales). Si desea presentar una queja por discriminación del programa de Derechos Civiles, complete el USDA Program Discrimination Complaint Form (formulario de quejas por discriminación del programa del USDA), que puede encontrar en internet en o en cualquier oficina del USDA, o llame al (866) para solicitar el formulario. También puede escribir una carta con toda la información solicitada en el formulario. Envíenos su formulario de queja completo o carta por correo postal a U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , por fax al (202) o por correo electrónico personas sordas, con dificultades auditivas, o con discapacidad del habla que deseen presentar sea una queja de EEO (Igualdad de Oportunidades en el Empleo) o del programa, por favor contacte al USDA por medio del Federal Relay Service (Servicio federal de transmisión) al (800) o (800) (en español). Las personas con discapacidades que deseen presentar una queja del programa, por favor vea la información anterior acerca de cómo contactarnos directamente por correo postal o por correo electrónico. Si necesita medios alternativos de comunicación para obtener información acerca del programa (Braille, caracteres grandes, cinta de audio, etc.) por favor contacte al Centro TARGET del USDA al (202) (voz y TDD).El USDA es un proveedor y empleador que ofrece igualdad de oportunidades. Member Agency Guidebook Form C- Updated May 23, 2014

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