ASC FOOD NUTRITION PROGRAM

FOOD NUTRITION PROGRAM
Registration Form
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Date of Birth (mm/dd/yyyy):

Month Day Year
Date
First Name, Middle Initial:
Last Name:
Address:
Phone Number:
City/State/Zip:
Email Address:
example@example.com
The following questions asking about your ethnicity and race are being asked for statistical purposes to make sure that we are giving fair and equal treatment to everyone. Your answers are voluntary and will have no effect on your senior services.
Ethnicity:

Hispanic or Latino Not Hispanic or Latino
Ethnicity:

American Indian or Alaskan Native Asian Black or African-American Native Hawaiian or Other Pacific Islander White Race (Check all that apply):
I certify that the information I have provided for my eligibility determination is correct, to the best of my knowledge. This certification 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 Federal Law.
Participant Signature:

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Month Day Year
Date
FOOD NUTRITION PROGRAM
Affidavit of Income
Participant Name (First, Last):
Participant Address:
I am providing this affidavit to verify my income
level as one of the following categories:

$23,606 or less annually for a one person household $31,894 or less annually for a two person household 40, 182 or less annually for a three person household 48,470 or less annually for a four person household $56,758 or less annually for a five person household $65,046 or less annually for a six person household $73,334 or less annually for a seven person household o$81,622 or less annually for an eight person household Other Specify annual income and household size
Income that meets the above listed criteria is 185% or less than the Federal Poverty Guidelines.
Applicant Signature:

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Month Day Year
Date
Should be Empty:

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FOOD NUTRITION PROGRAM

Registration Form

Complete All Lines

FOOD NUTRITION PROGRAM

Affidavit of Income