Form Application For Alaska Commodity Supplemental Food Program (Csfp) (Page 2 of 2) in pdf

Before signing, know your rights and responsibilities under the Commodity Supplemental Food Program (CSFP). By

checking the “yes” box next to the statements listed below, I am saying that I understand: (Reading help is available.)



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.

yes

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.



The local agency will provide notification of a decision to deny or terminate CSFP benefits within 10 days of application.

If you disagree with the denial or termination of assistance, you can request a Fair Hearing within sixty (60) days of the

decision, by contacting State of Alaska Family Nutrition Programs at 130 Seward Street, Room 508, Juneau, Alaska

99801; or call 907 465-3100. A request for a Fair Hearing shall be personally presented, either orally or in writing. A

request for an informal review must include: 1) name, address and contact phone number, 2) the reason for the grievance,

3) the action or relief sought; and 4) signature of applicant or representative. A Hearing Officer will arrange a date, time

and place convenient to both you and Family Nutrition Programs. In preparing for the hearing you have the right to

examine any documents, including records and regulations that are directly relevant to the hearing. You have the right to

be represented by counsel or any other person chosen as your representative. You have the right to a private hearing

unless you request a public hearing. You have the right to present evidence and arguments in support of your grievance

and to controvert evidence. You also have the right to cross-examine all witnesses. The Hearing Officer must render a

yes

decision within (14) days of the hearing. The decision of the Hearing Officer will be final.



The local agency will make nutrition education available to all adult participants,



The local agency will provide information on other nutrition, health, or assistance programs, and make referrals as

appropriate.



Improper use or receipt of CSFP benefits as a result of dual participation or other program violations may lead to a claim

against the individual to recover the value of the benefits, and may lead to disqualification from CSFP.



I must report changes in household income or composition within 10 days after the change becomes known to the

household.



I agree to inform the CSFP partner agency within 10 days of any changes in my contact information (i.e., my home address

or phone number), my income, or my household composition.



If I do not pick up my commodity foods for two months in a row, I may be considered an “inactive” CSFP participant and

removed from the program. If I choose to remain a participant in CSFP, I must notify the CSFP partner agency and

participate within the current certification period of my original application date.



CSFP recipients who are removed from the program for being “inactive participants” are allowed to re-apply for benefits by

filling out another CSFP application. If a waiting list exists, however, I understand my application will go on the list

according to the date it was received.



I must fill out a new CSFP application once a year. Every 6 months, I will need to verify my address, income and my

interest in continuing with the program.



I will treat all CSFP staff with courtesy and respect. Failure to do so may result in termination of assistance

Date

APPLICANT or Guardian/POA Agent

Signature

Printed Name of Applicant or Guardian/POA Agent

My approved alternate(s) (full name

If you would like to give permission for someone to pick up food on your behalf, please name them here.

CSFP Agency Use Only: If an application is signed by someone other than the applicant, CSFP regulations require CSFP agencies

to see Power of Attorney paperwork.

Power of Attorney paperwork reviewed by the Certifying Official?

yes

no Certifying official initials ____________

Revised 1/16

Form Application For Alaska Commodity Supplemental Food Program (Csfp) Page 2

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