Application For Food Distribution Form - 2013 Page 4
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8YOUR RESPONSIBILITIES AND RIGHTS
CASE NAME
YOU HAVE BOTH RESPONSIBILITIES AND
TO BE SURE YOU UNDERSTAND THEM.
RIGHTS – THINGS YOU MUST DO AND
ASK ANY QUESTIONS IF YOU DO NOT
THINGS YOU MAY EXPECT WHEN YOU
UNDERSTAND.
YOU ARE VERIFYING
APPLY. YOUR RESPONSIBILITIES AND
THAT
YOU
UNDERSTAND
YOUR
RIGHTS ARE LISTED ON THIS FORM.
RESONSIBILITIES AND RIGHTS WHEN
PLEASE READ THEM VERY CAREFULLY
YOU
(OR
YOUR
AUTHORIZED
REPRESENTATIVES) SIGN THIS FORM.
YOU HAVE A RIGHT TO:
YOU HAVE A RESPONSIBILITY TO:
1. Give true, correct, and complete information
1. Ask about the commodity program
on all forms including the application.
2. Apply for program benefits
2. Follow all applicable rules and regulations.
3. Get courteous and fair treatment with
3. Cooperate with FDPIR giving proof of your
no discrimination because of marital
situation and of the information you give. If
status, race, color, sex, national origin,
you are not able to give proof, give
handicap, political beliefs, age, or
permission to get it by signing this release
religious creed
form.
4. Get a decision on your eligibility for
4. Report the following to your worker:
benefits within 7 days
• Change of address
5. Be advised of the maximum monthly
• Any income that causes your household
income limit for your household size at
the time of initial certification and at
to exceed its maximum monthly income
each recertification.
limit
• Any change of persons living in your
home
• When anyone for whom you get
commodities gets a job or leaves a job
• When someone begins to get regular
money payments or there is a change in
the amount you get (for example: the
start of unemployment compensation or
a salary increase).
I have read (or have heard read to me) my responsibilities and rights. I understand what I must do and I agree to
carry out those responsibilities.
Signature of Applicant/Recipient(s):
________________________________________________________________
_________________________
SIGNATURE OF HEAD OF HOUSEHOLD
DATE
1220 Blosser Lane Willits, California 95490 ~ Phone: 707-456-1710 or 1712 ~ Fax: 707-456-1714 ~ E-mail: sherwoodvlyfdpir@sbcglobal.net
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