Senior Farmers Market Nutrition Program

Senior Farmers Market Nutrition Program Application

This is a secure application. An application must be completed for each person in the household that qualifies for SFMNP benefits. To qualify, individuals must meet the following criteria:

Age - person must be 60 years of age or older the day of issuance.
Income level - – to be eligible on the basis of income, recipients’ gross household income must not exceed the following limits:

$1,534.00 monthly……for a household of ------1
$2,064.00 monthly……for a household of ------2
$2,594.00 monthly……for a household of ------3
$3,124.00 monthly……for a household of ------4
$3,654.00 monthly……for a household of ------5
$4,183.00 monthly……for a household of ------6

(Household: a group of related or non-related individuals living together as one economic unit. These amounts are at 170% of 2010/2011 Federal Poverty Guidelines.)

No person is “entitled” to Senior Farmers Market Nutrition Program checks, i.e. the budget does not allow enough checks to satisfy everyone who wants them and is eligible.

Recipient Name / Date of Birth

First Name:
Middle:
Last:
Date of Birth:(Please use 5/16/2012 format)

Recipient Contact Information

Email:
Telephone: (Please use (555) 555-5555 format [include area code])
Mailing Address:
State:
County:
City:
Zip:

Race/Ethnicity

Race:American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Other
Prefer not to answer
Ethnicity:Hispanic
Non-Hispanic
Prefer not to answer

Household Information

Number of people living in your home:
Total monthly income for your household (include all income for the month): $

Verification

In order to verify that an actual person - not an automated software script - is submitting this form, please type the 2 words below in the box provided. If you can't read the words, click the blue "Get a new challenge" button.

Submission

Please read and agree to the following statement before typing your name in the box below.
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 may subject me to civil or criminal prosecution under State and Federal law. Standards for eligibility and participation in the SFMNP are the same for everyone regardless of race, color, national origin, age, handicap, or sex. I understand that I may appeal any decision made by the local agency regarding my eligiblity for the SFMNP.
Your full name:
The name you type above is used as your electronic signature. By typing your name in the box, you signify
that you agree with the information in this section and that the information you provided is accurate to the best of your knowledge.