Free 53250.pdf - Indiana

INDIANA STATE DEPARTMENT OF HEALTH

APPLICATION - SENIOR FARMERS' MARKET NUTRITION PROGRAM
State Form 53250 (4-07)

County _________________ PARTICIPANT INFORMATION First Name_______________

Date of Application ___/____/____

Last Name__________________

Address________________________________________________________ Street City State/ZIP Date of Birth ____/____/____ Household size ____________ Sex M F

The collection of race and ethnicity is requested solely for the purpose of determining the State agency's compliance with Federal civil rights laws, and ensures that the program is administered in a non-discriminatory manner. Your responses to these questions will not affect consideration of your application. If you choose not to self-identify race and ethnicity, the person taking the application must record the participant's race and ethnicity based on visual observation. ETHNICITY CATEGORY HISPANIC OR LATINO NOT HISPANIC OR LATINO RACE CATEGORY (select one or more) AMERICAN INDIAN OR ALASKA NATIVE ASIAN BLACK OR AFRICAN AMERICAN NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER WHITE MULTI-RACIAL (PLEASE SPECIFY ABOVE) To be eligible to receive Senior Farmers Market Nutrition Program (SFMNP) checks, you must be at least 60 years of age and meet the income guidelines, which are based on 185% of the Federal Poverty Income Guidelines during the current fiscal year and live in the county where the checks are being issued. I have been given a copy of the current income guidelines for this fiscal year. CURRENT PARTICIPANT Food Stamps TANF CFSP Member of a WIC Household Monthly Income: ________________ Applicant eligible? Yes Income eligible? Yes No

given SFMNP Checks

Put on wait list

Issued SFMNP checks numbers _______________through _________________

No

If no;

denial provided to client Date_________________________

PROXY A proxy is a person only authorized to receive and/or redeem SFMNP checks. A proxy should be at least 18 years of age and dependable for the duration of the program months of operation. In order for the checks to be issued to a proxy, the proxy must be present identification as well as written approval from the participant. Proxies must sign the check register to receive checks. Proxies have the same obligations to follow program guidelines when purchasing fruits and vegetables from an authorized farmer. I, ________________________ authorize the following individual(s) to act as my proxy. Participant signature Assigned proxies: ________________________ 1st proxy named _________________________ 2nd proxy named

Check here if no proxy was assigned
CERTIFICATION BY PARTICIPANT I have been advised of my rights and obligations for use of SFMNP Checks. I certify that that the information I have provided for my eligibility determination is correct, to the best of my knowledge. I am aware that I cannot receive farmers' market benefits from more than one state or more than one local agency. This application 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 Indiana SFMNP program are the same for everyone, regardless of race, color, national origin, age, disability or sex. I understand that I may appeal any decision made by the local agency regarding my eligibility for the SFMNP program. I certify I meet the 2007 household size and income guidelines provided by the state and that I am eligible to receive SFMNP benefits. ____________________________________________ Signature of Participant _____________________________________________ Signature of Staff/Volunteer _________________ Date _________________ Date

Do you or any adult household members have: Diabetes COPD Heart Disease Arthritis Osteoporosis Cancer Asthma High Blood Pressure

Obesity (more than 15 lbs overweight)

Other: Please list: _________________________ YES NO If yes, please indicate all

Are you participating in other food programs? that apply: Commodities Other, please list:

Local food bank Food Stamps __________________________

Emergency food (TFAP)

"This institution is an equal opportunity provider and employer."