Applicants must reapply every year. An application must be completed for each person in the household that qualifies for SFMNP benefits.

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 and then click Submit. You should receive a message that the application has been successfully submitted. A confirmation email will be sent to the email address that is 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 - person must be 60 years of age or older the day of application, AND

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:

Residence Address Apt:

City:

State:

Zip:

Email:

County:

Phone:

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

Mailing address same as Residence address:

Mailing 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.

Example: If you have a husband and wife who are both eligible and are applying for the benefits you would enter one application for the husband with his name, date of birth, and with 2 people living in the home and their combined household income amount. You would then enter another application with the wife’s name and information and put 2 people living in the home and the same combined household income amount. If there are 5 people in the home and only 3 receive income you would still enter it as 5 people in the home and whatever the combined income of those 3 people would be.

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).

List other federal assistance programs the participant is enrolled in? (i.e. Medicaid, 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?

For the purposes of assessing the effectiveness of USDA’s programs and the level of outreach, please check the race or ethnicity of the applicant.

Racial/Ethnic Group – Check one or more:

SECTION 5

This section must be read by the applicant, or if requested, read to the applicant before the applicant signs and dates the form.

This certification information is being submitted in connection with the receipt of Federal assistance.  I certify that the information I have provided for my eligibility determination is correct, to the best of my knowledge.   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 my paying the State agency in cash, the value of the food benefits improperly issued to me and may subject me to civil penalties or criminal prosecution under state and federal law.  I also understand that obtaining Senior FMNP benefits from more than one service delivery area is a violation of program rules.

Standards for eligibility and participation in the SFMNP are the same for everyone, regardless of race, color, national origin, age, disability, or sex.

I have read and understand my rights and obligations under the SFMNP which are listed in section 6 below. I understand that I may appeal from any decision made by the state agency regarding my eligibility for the SFMNP.

Signature:

Signature Date:

Signature of preparer if not the applicant:

SECTION 6

SFMNP Participant’s Rights and Obligations

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. USDA is an equal opportunity provider.