DIRECTIONS: Once you have completed the required fields, click the CONTINUE button at the bottom and you will be directed to a review page. Once there, confirm all the information is accurate, then click SUBMIT. Once the application has been successfully submitted, a confirmation email will be sent to the email address provided on the application.

SECTION 1

Read each eligibility requirement and then mark each statement in Section 1 that applies. To qualify, individuals must meet the following criteria:

Age - An applicant must be 60 years of age or older the day of application,

Income level - Recipients’ gross household income (income before taxes) must not exceed the following limits:

SECTION 2

Enter the applicant's name, date of birth, gender, residential address, mailing address (if different than the residential address), phone number and county that the applicant resides.

First Name:

Middle Name:

Last Name:

Date of Birth:

Gender

Residence Address:

Apt:

City:

State:

Zip:

Email:

County:

Phone:

If you wish to receive a confirmation email that your application has been received, please enter a valid email address.

Mailing address same as Residence address:

Mailing Address:

Apt:

City:

State:

Zip:

SECTION 3

In this section, the applicant should:

Household Income: Include the number of ALL people living in the home and the total monthly income for ALL individuals in the household.

NOTE: An application must be completed for each individual applying for program benefits.

Number of people living in the home:

Total gross MONTHLY income for your household $

(include any and all income for the month for ALL individuals in the home).

ENTER $1.00 IF THERE IS 0 HOUSEHOLD INCOME.

List other federal assistance programs the participant is enrolled in? (i.e. Medicare, CSFP, SNAP)

I authorize the following person(s) to serve as my proxy to accept SFMNP cards for me and use at an authorized farmers’ market (optional):

Person 1:

Person 2:

SECTION 4

Is the applicant Hispanic or Latino? Please check yes or no.

Are you Hispanic or Latino?

Please check the applicant’s race or ethnicity to assess the effectiveness of USDA’s programs and the level of outreach.

Racial/Ethnic Group – Check one or more:

SECTION 5

THE FOLLOWING INFORMATION MUST BE READ BY THE APPLICANT, OR TO THE APPLICANT BEFORE SIGNATURE:

Certification Regarding Rights & Obligations

I certify that the information I have provided for my eligibility determination is correct, to the best of my knowledge. This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the state agency, in cash, the value of the food benefits improperly issued to me and I may subject to civil or criminal prosecution under state and federal law. I have been advised that food benefits issued to me are only for my personal use and offering to sell them verbally, in print or online may result in paying the State agency, in cash, the value of the food benefits improperly disposed of and may subject me to disqualification and civil or criminal prosecution under State and Federal law. I have been advised of my rights and obligations under the SFMNP.

Directions of how and where to use SFMNP benefits can be found here.

Certification Regarding Dual Participation

Application to receive food benefits in more than one county or area, or more than once under a separate name is illegal and may subject me to disqualification, cash repayment of the value of benefits, and/or civil or criminal prosecution under State or Federal law. Therefore, I have been advised that it is illegal to be a dual participant in the SFMNP.

Signature:

Signature Date:

Signature of preparer if not the applicant:

SECTION 6

APPEAL RIGHTS

I understand that I may appeal any decision made by the state agency regarding my eligibility for the SFMNP to the following:

Purvie Green, SFMNP Coordinator
Mississippi Department of Agriculture and Commerce
121 North Jefferson Street
Jackson, MS 39201
Tel.: (601) 359-1168 Fax: (601) 354-6290
email: purvie@mdac.ms.gov

USDA NONDISCRIMINATION POLICY

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, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. 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 State or local Agency that administers the program or contact USDA through the Telecommunications Relay Service at 711 (voice and TTY). Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint 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, Mail Stop 9410, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.