Senior Farmers Market Program Online Application

Client Information
Name*
First Middle Initial Last
Date of Birth*
MM
DD
YYYY
Age*
Sex*
- Male
- Female
Home Address*
This is where we will deliver your produce box, if you are accepted into the 2020 program.

Street Address Apt # City 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.
Phone*
Please provide your cell phone number, if you have one that you use.
Ethnicity*
Select one.
Select one or more. Information collected for federal statistics.*
- American Indian/Alaskan Native
- African-American/Non-Hispanic
- Asian
- Pacific Islander/Native Hawaiian
- White
Which of the following reflects your TOTAL household income?*
- 1 person in household, income of $0 - $23,107
- 2 persons in household, income of $0 - $31,284
- 3 person in household, income of $0 - $39,461
- 4 person in household, income of $0 - $47,683
- 5 person in household, income of $0 - $55,815
- 6 person in household, income of $0 - $63,992

Produce Box Selection
Please indicate if you would prefer a mid-summer or a late-summer produce box to be delivered to you. LifeCare Alliance and COAAA cannot guarantee that this is what you will receive, but we will do our best to accommodate your request.*
- Mid-Summer
- Late-Summer

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:
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.
This institution is an equal opportunity provider.

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.
Applicant Signature
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.
Date
Date Format: MM slash DD slash YYYY

Senior Farmers Market

2020 Senior Farmers’ Market Nutrition Program

Online Application

Step 1 of 4

Client Information

Produce Box Selection

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.

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