Senior Farmers Market Nutrition Program (SFMNP)

Senior Farmers Market Nutrition Program

STATEMENT OF ELIGIBILITY
Last Name
First Name
Birth Date

Month Day Year
Gender
Street Address:
City/Town
State
Zip Code
County
Phone Number
Race

American Indian Asian Black or African American Native Hawaiian or Pacific Islander White
Ethnicity (select yes or no) Hispanic or Latino?

Yes No
I certify that:

I. I am:

a. 60 years of age or older; AND

b. My monthly income is at or beloe the federal income guidelines for my household outlined in SFMNP Policy Memorandum #2020-2

i. $1,968/month (for a one-person household): OR

ii. $2,658/month (for a two-person household): OR

iii. $3,349/month (for a three-person household)

II. I have not received SFMNP checks from any other location this year

III. I have been advised of my rights and obligations under the SFMNP. I certify that the information I have provided for my elgibility determination is correct, to the best of my knowledge. This cerification form is being submitted in connection with the receipt of Federal assistance. 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 Federa Law.
Electronic Signature
Date:
Please allow 2-3 business days for processing. Farmers Market Coupons will be mailed to the address provided.
- Each booklet is worth $20.00 and contains five (5) $4.00 coupons.
- Coupon color for this program year is toasted marshmallow.
- Eligibility is determined by age and income
- Each older adult in a household is eligible to receive a booklet if they meet the age and income requirements.
Should be Empty: