CAPECO721 SE 3rd, Suite DPendleton, OR 97801541-276-5073 | 800-752-1139
All fields marked with an asterisk (*) are required.
Recertification is allowed within 30 days of the expiration of the previous certification.
Based on the information you have provided, for us to determine your continued eligibility, you will need to fill out the
Food Distribution Program on Indian Reservations Application
If your household receives USDA foods, it must follow the rules listed below. Failure to comply with these rules may result in a monetary claim being filed against the household and/or disqualification from participation in the Food Commodity Program.
DO NOT give false information or hide information to get, or continue to get, food distribution commodities.
DO NOT trade or sell food distribution commodities.
DO NOT use someone else’s food distribution commodities for your household.
I understand the questions on this recertification. The answers I provided are correct and complete to the best of my knowledge.
I understand that dual participation in both the Food Stamp Program (Cal-Fresh) and the Food Commodity Program is illegal.
I understand that I have to provide documents to prove what I said. I agree to do this. If documents are not available, I agree to give the name of a person or organization the office may contact to obtain this necessary proof.
RIGHT TO REQUEST FAIR HEARING:
You or your representative may request a fair hearing either orally or in writing if you disagree with any action taken on your case. You may also continue to receive the same level of benefits pending the outcome of the hearing. Your case may be presented at the hearing by any one you choose.
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:
This institution is an equal opportunity provider.