721 SE 3rd, Suite D
Pendleton, OR 97801
541-276-1926 | 800-752-1139

 

Serving Gilliam, Hood River, Morrow, Sherman, Umatilla, Wasco, and Wheeler counties

All fields marked with an asterisk (*) are required.

Please read this page before filling out the form.

Answer all questions.

A copy of this page will be emailed to you after you submit this application.  You will also have the option to print this form before you submit it.  Keep it for your records.

 

HOW DO I APPLY FOR THE COMMODITY SUPPLEMENTAL FOOD PROGRAM (CSFP)?

This application is for the CSFP Program. To determine if you qualify, you must submit this application to CAPECO. You must meet certain program requirements to participate in the program. This program allows specified nutritional foods and offers information on nutritional needs.

To apply, you must:

• Complete this form with all the necessary information;
• Self-declaration of income or no-income
• Show proof of statements you make on this form, specifically:
  • Proof of residence
  • Picture ID

 

HOW DO I APPLY FOR OTHER PROGRAMS AND SERVICES?

You must contact: CAPECO located at 721 SE 3rd Suite D in Pendleton, OR. 97801 or the CAPECO office located at 1565 N First St. Space #1 in Hermiston, OR. 97838. You can also call CAPECO at 541-276-1926 if you want to apply for other services and programs offered by the agency.

 

HEARING RIGHTS FOR THE CSFP PROGRAM ONLY:

“Standards for participation in the Program are the same for everyone regardless or race, color, national origin, age, sex, and disabilities; you may appeal any decision made regarding your written denial or termination from the Program. If your application is approved, nutrition education will be made available to you and you are encouraged to participate.”

If you disagree with denial or termination of assistance, you can request a fair hearing within sixty (60) days of the decision by contacting CAPECO. A request for a fair hearing shall be personally presented, either orally or in writing. A request for an information review must include: 1) Name, address and contact phone number, 2) the reason for the grievance, 3) the action of relief sought.

A hearings officer will arrange a date, time and place convenient to both you and CAPECO. In preparing for the hearing you have the right to examine any documents, including records and regulations that are directly relevant to the hearing. You have the right to be represented by counsel or any other person chosen as your representative. You have the right to a private hearing unless you request a public hearing. You have the right to cross-examine all witnesses. The hearings officer must render a decision within fourteen (14) days of the hearing. If you disagree with the decision of the hearing officer, you may pursue a judicial review.

 

DATA COLLECTION:

Racial and/or ethnic data collected on this form have no effect on the eligibility determination of the household. Thank you for filling out this form as accurately and completely as possible. The federal government is requesting this information in order to monitor compliance with the federal statutes that prohibit federally assisted programs from discriminating against applicants on this basis. Information obtained will be kept confidential and used for statistical analysis only. Racial and ethnic information is voluntary.

 

NUTRITION EDUCATION:
The local agency will make nutrition education available to all adult participants, and to parents or caretakers of infant and child participants, and will encourage them to participate. The local agency will provide information on other nutrition, health or assistance programs, and make referrals as appropriate.

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.

Commodity Supplemental Food Program: Notice of Beneficiary Rights

Because this program is supported in whole or in part by financial assistance from the Federal Government, we are required to let you know that—

• We may not discriminate against you on the basis of religion or religious belief, a refusal to hold a religious belief, or a refusal to attend or participate in a religious practice;
• We may not require you to attend or participate in any explicitly religious activities that are offered by us, and any participation by you in these activities must be purely voluntary;
• We must separate in time or location any privately funded explicitly religious activities from activities supported with USDA direct assistance;
• If you object to the religious character of our organization, we must make reasonable efforts to identify and refer you to an alternate provider to which you have no objection. We cannot guarantee, however, that in every instance, an alternate provider will be available; and
• You may report violations of these protections (including denials of services or benefits) by an organization to the State agency (FAP.CSFP-TEFAP@state.or.usThe State agency will respond to the complaint and report the alleged violations to their respective USDA FNS Regional Office (http://www.fns.usda.gov/fns-regional-offices).

We must provide you with this written notice before you enroll in our program or receive services from the program, as required by 7 CFR part 16.

COMMODITY SUPPLEMENTAL FOOD PROGRAM APPLICATION

In order for CAPECO to determine eligibility for this application you will need to provide proof of identity and residence. You may take a picture of your state issued ID or passport and upload it here as proof or send a copy of your proof of identity and residence to us.

• To upload, read the entire terms and conditions and select the first box.  
• To mail, check the second box.

CLIENT CHARACTERISTICS

ETHNIC ORIGIN:

AUTHORIZED REPRESENTATIVE:

You can authorize up to two people outside your household to get your food commodities for you.

• I consent to any legally authorized investigation for confirmation of any information that I provide. I agree to let the State of Oregon Department of Human Services give information to DHS, LCA or Oregon Food Bank to determine my eligibility.
• I acknowledge that I have received the first page of this application outlining my rights to request a fair hearing if my application is denied. I understand that I must request a hearing within sixty (60) days of the written date of denial.
• I CANNOT sell or trade commodities or use someone else’s commodities for my household.
• I also agree to inform the CSFP office if my household income or composition changes. I will provide the new information within ten (10) days of the change.
• The local agency will make nutrition education available to all adult participants, and to parents or caretakers of infant and child participants, and will encourage them to participate
• The local agency will provide information on other nutrition, health or assistance programs, and make referrals as appropriate
• Improper use or receipt of CSFP benefits as a result of dual participation or other program violations may lead to a claim against the individual to recover the value of the benefits, and may lead to disqualification from CSFP

This application is being completed in connection with the receipt of Federal assistance. Program officials may verify information on this form. I am aware that deliberate misrepresentation may subject me to prosecution under applicable State and Federal statutes. I am also aware I may not receive both CSFP and WIC benefits simultaneously, and I may not receive CSFP benefits at more than one CSFP site at the same time. Furthermore, I am aware that the information provided may be shared with other organizations to detect and prevent dual participation. I have been advised of my rights and obligations under the program. I certify that the information I have provided for my eligibility determination is correct to the best of my knowledge.

Staff Member Signature  _____________________________________________

Date ___________________

FOR OFFICE USE ONLY: ID Type Provided: ______________________________________    ☐ APPROVED     ☐DENIED     ☐NOTICE OF ACTION _________________ Date: _____________ Staff Initial ___________________ Remarks: ___________________________________________________ ___________________________________________________________

Annual review of eligibility:   Participant eligible and interested in participation           ☐Yes ☐No Staff initial:_______ Date: ___________   Participant eligible and interested in participation           ☐Yes ☐No Staff initial:_______ Date: ___________