Form Application For Alaska Commodity Supplemental Food Program (Csfp) printable pdf download

APPLICATION FOR ALASKA COMMODITY SUPPLEMENTAL FOOD PROGRAM (CSFP)

CSFP Partner Agency:

(ONE APPLICATION PER PERSON)

APPLICANT: The Applicant’s eligibility for CSFP is based upon the following statements. A separate application is required for each Applicant.

Are you 60 years old or older?

YES

Do you meet the Income Eligibility Guidelines for CSFP?

YES

Please print and complete all information.

Name of Applicant: ______________________________________________________ Birth Date: _______/_______/__________

(Last)

(First)

(Middle)

YYYY

Mailing

Address: ________________________________________________________________________, AK

Zip_________________

Street or PO Box

Apt #

City

Physical

Address (if different): ______________________________________________________________, AK

Zip_________________

Street

Apt #

City

Home Phone __________________________________ Message Phone: _____________________________________________

Are you Hispanic or Latino? (Please choose only one):

YES

What is your race? (Please choose one or more)

Alaska Native/American Indian;

Asian;

Black/African American;

Native Hawaiian/Pacific Islander;

White.

Racial and/or ethnic data collected on this form has NO EFFECT ON THE ELIGIBILITY DETERMINATION OF THE HOUSEHOLD.

Primary language:

How many people in your household?

Total household income before deductions: $

per

month,

year.

Did anyone in your household receive the latest AK Permanent Fund Dividend?

yes

no If yes, how many?

If yes, did you

include this amount in your total household income listed above?

yes

(Your PFD or other garnished income is considered income even though it is garnished and must be added to your total household

income.)

The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the

bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal and, where applicable, political beliefs, marital status,

familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected

genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all

programs and/or employment activities.)

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at

, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a

letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of

Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at

program.intake@usda.gov.

Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint please contact USDA

through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).

Persons with disabilities who wish to file a program complaint, please see information above on how to contact us by mail directly or by email. If

you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA's

TARGET Center at (202) 720-2600 (voice and TDD).

USDA is an equal opportunity provider and employer.

CSFP Agency Use Only:

Eligible

Ineligible- Reason ________________

Date of Certification: ________________

Date App Received ___________ Date Notified of Status________________

Signature of certifying official:

Date:

Printed name of certifying official:

Phone: ______________

Revised 5/15

Form Application For Alaska Commodity Supplemental Food Program (Csfp)

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