California Food Stamp Application Page 5

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Application for Food Stamp Benefits
Important Information
➤
The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs
and activities on the basis of race, color, sex, religion, national origin, or political beliefs.
You may file a complaint if you think you have been discriminated against. If you
disagree with the decision of the county, an appeal process is available to you.
➤
The information on this application may be shared with federal, state and local agencies
only for the purposes of verifying eligibility for the Food Stamp Program. This process
may include confirmation with the U.S. Citizenship and Immigration Services (USCIS)
(formerly INS) of the immigration status only of those persons seeking food stamp
benefits. Federal law says the USCIS cannot use the information for anything else except
cases of fraud.
Signature
I certify under penalty of perjury under the laws of the United States of America and the
State of California that the information I have provided on this application is true, correct
and complete.
Signature (Adult Household Member or Authorized Representative)
Date
Signature of Witness or Interpreter
Date
Signature of Eligibility Worker
Date
page 3 of 3
DFA 285 A1 (4/09) REQUIRED FORM – NO SUBSTITUTES PERMITTED

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