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ABOUT
–
OUR LEADERSHIP
OUR STORY
JOIN OUR TEAM
E-NEWSLETTER
–
PHOTO GALLERY
ANNUAL REPORT
LOCATIONS
CONTACT US
PROGRAMS
–
REFER A CLIENT
CENTRAL OHIO DIABETES ASSOCIATION
DIABETES DAYTON
COLUMBUS CANCER CLINIC
MEALS-ON-WHEELS
SENIOR FARMERS MARKET
WELLNESS
–
CARRIE’S CAFE & SENIOR DINING CENTERS
HELP-AT-HOME
IMPACT SAFETY
Project OpenHand
SENIOR PETCARE
VISITING NURSES
SUPPORT
–
DONATE
PLANNED GIVING
LEGACY ENDOWMENT CAMPAIGN
ENDOWMENT RESOURCE DIRECTORY
LIFECARE ALLIANCE STORE
–
SHOPPING REWARDS
Cancer Thrift Shops
SOCIAL ENTERPRISE
VOLUNTEER
VOLUNTEER APPLICATION
Blog
Referrals
Volunteer
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Senior Farmers Market
2021 Senior Farmers’ Market Nutrition Program
Online Application
Step
1
of
4
25%
Client Information
Each applicant must complete and submit a separate application for each program year.
Name
*
First
Last
Date of Birth
*
Age
*
Sex
*
Male
Female
No Answer
Home Address
*
This is where we will deliver your produce box, if you are accepted into the 2021 program.
Street Address
Apt #
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
If you have an email address that you use, please provide it so that we may easily communicate with you.
County
*
Please select the county where you live.
Please select one
Fairfield
Fayette
Franklin
Licking
Madison
Pickaway
Union
Phone
*
Please provide your cell phone number, if you have one that you use.
Race
*
Select all that apply
American Indian/Native Alaskan
Asian
Black/African-American
Native Hawaiian/Pacific Islander
White
Other
Nationality
*
Select all that apply.
Arabic
Chinese
Europe, the Middle East, or North African origins
Far East, Southeast Asia, Indian subcontinent origins
Hawaii, Guam, Samoa, Pacific Islands origin
Of Spanish origin or culture, regardless of race
Origins in black racial groups of Africa
Of an ethnic race other than those listed
Which of the following reflects your TOTAL household income?
*
1 person in household, income of $0 - $23,828
2 persons in household, income of $0 - $32,227
3 person in household, income of $0 - $40,626
4 person in household, income of $0 - $49,025
5 person in household, income of $0 - $57,424
6 person in household, income of $0 - $65,823
Authorized Shopper
Please complete the following information ONLY if applicant is designating an authorized shopper.
Authorized Shopper Name
First
Last
Relationship to Participant
Authorized Shopper Phone Number
USDA Nondiscrimination Statement
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:
mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;
fax: (202) 690-7442; or
email: program.intake@usda.gov.
This institution is an equal opportunity provider. To download a copy of this statement,
click here
.
Nondiscrimination Statement Acknowledgement
*
Please check here to acknowledge that you have reviewed the USDA Nondiscrimination Statement
Signature
I certify that I am at least 60 years of age; a resident of this service area; have not received coupons at any other location; and total household income requirements are met.
I have been advised of my rights and obligations under the SFMNP. I certify the information I have provided is correct. This form is being submitted for Federal Assistance and is subject to verification. I understand that 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. I understand that I may appeal any decision made by the local agency regarding my eligibility for the SFMNP. Information will not be shared except for the specific purposes of responding to your request for assistance.
Applicant Signature
Date
MM slash DD slash YYYY