Commodity Supplemental Food Program (CSFP) Application

(Recertification due every 36 months)

Is this a Recertification?*

NoYes

Please select the County where your CSFP Distribution Site is located*

Fairfield County: Please select your CSFP Site Name

Hartford County: Please select your CSFP Site Name

Litchfield County: Please select your CSFP Site Name

Middlesex County: Please select your CSFP Site Name

New Haven County: Please select your CSFP Site Name

New London County: Please select your CSFP Site Name

Tolland County: Please select your CSFP Site Name

Windham County: Please select your CSFP Site Name

CSFP Distribution Site Name

This field will Autofill

Are you seeing numerous duplicate entries on your spreadsheet?

Please use the edit function to make the following changes:

Name change (marriage, divorce etc.)
Address Change (client moved)
Status change: (Left program, deceased, denied, approved, wait list)
Income change
Proxy added or removed

Here are some tips to make this process more efficient for everyone.

Is this a RECERTIFICATION?

If you don't know, check your spreadsheet.
If they are ON the spreadsheet, you need to find the last email and use it to EDIT the form.
You must also enter "YES" for "Is this a Recertification?"

SPELLING

Each time ANY client data changes in ANY of the fields, it will create a duplicate entry. This includes:

first name, last name
street address
apartment number
town or city name
zip code
birthday

Addresses

Do not abbreviate town names (example: WH could mean West Haven or West Hartford).
Enter Apartment numbers in the appropriate field.
Be consistent. If the client lives in Apartment 4J and you entered it 4-J last time, continue with 4-J unless that is not correct.
State: Use the dropdown to select the state of Connecticut.

Use the EDIT Feature:

Using the EDIT feature to correct errors DOES NOT create a dupllicate record.

If you make a spelling mistake, EDIT the form as soon as you are aware.

A box pops up with every submission, there is a link to edit there.
You will also receive an email with a link to edit. This is the same process as Recertifying. All client data will auto-fill, just correct any errors.

Name*

First NameLast Name

Address*

Street Address

Apartment Number

CityState

Zip Code

Autocompleted Address

Email

example@example.com

Date of Birth*

Date

Primary Phone Number*

Please enter a valid phone number.

Alternate Phone Number

Please enter a valid phone number.

Total Number of People in Household:*

Number of People age 60 or older in Household:*

Will somebody else be picking up your CSFP box?*

YesNo

Is an Individual or an Organization going to serve as the proxy?*

An IndividualAn Organization

Proxy's Name*

First NameLast Name

Contact Person at the Organization*

First NameLast Name

Proxy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Proxy Phone Number*

Please enter a valid phone number.

Please tell us about your race and ethnicity for data collection and reporting purposes. Providing this optional data will not affect your eligibility.

Ethnicity

Hispanic or Latino/aNot Hispanic or Latino/a

Race (you may select more than one)

Are you currently receiving food through CSFP?*

YesNo

Have you received food through CSFP in the past?*

YesNo

What is your family unit's gross monthly income?*

Use GROSS MONTHLY income rounded up to nearest dollar. Max is set at $9,999.

Is your family unit's gross income less than the amount listed below?*

YesNo

Please indicate your decision by checking one of the following boxes:*

YesNo

Signature*

Date

Applicant has received "Written Notice of Benificiary Rights"*

Yes

Status*

ApprovedWait ListDeniedLeft Program or Deceased

Approval Date

Date

End Date of Cert. Period

Approval Date PLUS THREE YEARS

Recertification Date

Date

Date Put on Wait List

Date

Denied Date

Date

Left Program or Deceased Date

Date

Date Letter of Fair Hearing Given

Date

Staff Name*

First NameLast Name

Staff Signature*

Date Signed*

Date

Staff Email (to receive confirmation of submission)*

example@example.com

Commodity Supplemental Food Program (CSFP) Application

Client Information