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Senior Farmers’ Market Nutrition Program (SFMNP) Voucher Application
Address Line 2
State / Province / Region
ZIP / Postal Code
Date of Birth
MM slash DD slash YYYY
Gender, Ethncity, and Race
The collection of gender, race, and ethnicity is requested solely for the purpose of determining the state agency's compliance with Federal civil rights laws and ensure 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 gender, race, and ethncity, then the person taking the application must record the participant's race and ethnicity based on visual observations. (7 CFR 249.7(a)(vi))
Hispanic or Latino
Not Hispanic or Latino
Select one or more.
American Indian or Alaska Native
Black or African American
Native Hawaiian / Pacific Islander
To be eligible to receive Senior Farmers' Market Nutrition Program (SFMNP) checks, you must be at least sixty (60) years of age (or a person with disabilities, under age sixty (60), currently living in a housing facility occupied primarily by older persons where congregate nutrition services are provided); meet the income guidelines, which are based on 185% of the Federal Poverty Income Guidelines; and live within the service area of the administering local agency.
Do you or a household member currently receive benefits from any of the following programs?
SNAP (Food Stamps)
None of the above
(from all sources; before taxes or deductions, for all household members)
Number in Household
A proxy is a person you authorize to receive and/or redeem SFMNP checks on your behalf. A proxy must be at least eighteen (18) years of age and should be dependable for the duration of the program season. 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 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.
Check here if no proxy is authorized.
I have been advised of my rights and obligations under the program. I certify that the information I have provided for my eligibility is correct to the best of my knowledge. I am aware that I cannot receive SFMNP benefits from more than one state or more state or more than one local agency. This application is submitted in connection with a federal benefit. 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. I understand that I may appeal any decision made by the local agency regarding my eligibility for the SFMNP program. I attest that household size and income listed on this application are accurate.
MM slash DD slash YYYY
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 the 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 language other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complain Form, (AD-3027) found 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 complain 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: firstname.lastname@example.org. This institution is an equal opportunity provider.
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