Free 53251.pdf - Indiana

INDIANA STATE DEPARTMENT OF HEALTH

NOTIFICATION OF INELIGIBILITY ­ SENIOR FARMERS' MARKET NUTRITION PROGRAM
State Form 53251 (4-07)

Date of Application: ___/____/____ PARTICIPANT INFORMATION

Today's Date___/____/____

First Name______________________________ Last Name_________________________

Dear Applicant:

Your application for the SFNMP checks for 2007 was denied for the following reasons: You are not enrolled in a Area Agency on Agency You are not a resident of Indiana You are not over age 60 or a qualified disabled person You do not meet income guidelines You are being put on a waiting list for benefits
I understand that I may appeal any decision made by the local agency regarding my eligibility for the SFMNP.

____________________________________________ Signature of Applicant _____________________________________________ Signature of Staff/Volunteer

_________________ Date _________________ Date

To appeal call___________________________or contact the Indiana State Department of Health SFMNP Coordinator at 1-800-522-0874. This program is administered by the Indiana State Department of Health, Community Nutrition Obesity Prevention Division; Section 2L, Indianapolis, IN 46204

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