Michigan Commodity Supplemental Food Program Application

*Proxy Authorization*

I authorize the following individual(s) or entity to pick up my commodity box for me:

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 that 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. I authorize the release of information provided on this application form to other organizations administering assistance programs for use in determining my eligibility for participation in other public assistance programs and for program outreach purposes. (Please indicate decision by placing a checkmark in the appropriate box

Household of 1: Annual income limit of $16,744, or a monthly income limit of $1,396 Household of 2: Annual income limit of $22,646, or a monthly income limit of $1,888 Household of 3: Annual income limit of $28,548, or a monthly income limit of $2,379 For each additional family member add: $5,902 annually, or $492 monthly

• The Agency will provide written notification of approval or denial of the application within 10 days of receipt of the completed application.
• If the application is denied, you have the right to appeal this decision by requesting a fair hearing within 60 days of notification.
• Improper use or receipt of CSFP benefits because of dual participation or other program violations may lead to a claim against you to recover the value of the benefits and may lead to disqualification from CSFP.
• You must report changes in contact information (i.e., home address, phone number) or household income or composition within ten (10) days after the change becomes known to the household.
• If you do not pick up commodity foods for three consecutive months, you may be considered an “inactive” CSFP participant and removed from the program. If you choose to remain a participant in CSFP, you must notify the Agency and participate within the current certification period of your original application date.
• CSFP recipients who are removed from the program for being “inactive participants” can re-apply for benefits by filling out another CSFP application. If a waiting list exists, you will go on the list according to the date it was received.
• Once a year, you will need to verify your address, income, and interest in continuing with the program.
• This application is valid for three years and a new one will need to be filled out at that time.
• The Agency will make nutrition education available to all participants and will encourage them to participate.
• The Agency will provide information on other nutrition, health, or assistance programs, and make referrals as appropriate.
• Standards for participation in this program are the same for everyone regardless of race, color, national origin, age, sex, and disability.
• You are required to show proof of identity at each distribution.

1. The Supplemental Security Income (SSI) program. This program pays benefits to disabled adults and children who have limited income and resources. SSI benefits also are payable to people 65 and older without disabilities who meet the financial limits. Phone: Toll-free at 1-800-772-1213 (TTY 1-800-325-0778 Online: www.ssa.gov/agency/contact 2. Medical assistance. Medicare is our country’s health insurance program for people aged 65 or older. Phone: Toll-free at 1-800-772-1213 (TTY 1-800-325 0778 Online: www.medicare.gov 3. Supplemental Nutrition Assistance Program (SNAPSNAP is a federal program that gives assistance for low-income individuals and families to purchase nutritious food. Individuals and families qualify for SNAP benefits based on their income. Phone: Toll-free at 1-888-678-8914. Online: www.michigan.gov/mdhhs

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: How to File a Complaint , 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: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400

Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. This institution is an equal opportunity employer.