CSFP Request Form

Fill out this form to see if you are eligible for the Commodity Supplemental Food Program.

Eligibility for the CSFP food boxes is based on age, income, and residency. Our CSFP coordinator will contact you to verify eligibility and determine your nearest distribution site.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone

Date of Birth(Required)

Household Income

What counts as income?

What are the income guidelines for CSFP?

Total Number of Household Members(Required)

Please enter a number greater than or equal to 0.

Total gross income (before deductions) of all household members(Required)

Please enter a number greater than or equal to 0.

How often?(Required)

This institution is an equal opportunity provider.

CICOA Aging & In-Home Solutions is committed to your privacy and to the protection of your personal information. Your information is submitted securely and will only be used for the purposes of the CSFP program.