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    May 26, 2019
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; SENIOR FARMERS MARKET NUTRITION (VOUCHER) PROGRAM The Area Agency on Aging for Luzerne & Wyoming Counties announces the Distribution Schedule of the Senior Farmers Market Nutrition Vouchers provided by the United States and Pennsylvania Departments of Agriculture COMMONWEALTH OF PENNSYLVANIA | DEPARTMENT OF AGRICULTURE SENIOR FARMERS' MARKET NUTRITION PROGRAM |2019 ELIGIBILITY & PROXY FORM RIGHTS AND RESPONSIBILITIES. I have been advised of my rights and obligations under the SFMNP. lcertily that the information I have provided for my eligibility determination is correct, to the best of my knowledge. This certification form is being submitted in connecion with the receipt of Federal assistance. Program officials may verly information on this form. I understand that intentionally making a talse or misleading statement or intenticnaly misrepresenting, concealing, or withhokding facts may result in paying the Sate agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law Standards for eligibality and participation in the SFMNP are the same for everyone, regardless of race, color, national origin, age, disabiity, or sex l understand that I may appeal any decision made by the local agency regarding my ellgibiity for the SFMNP Participant Name (Print) Birthday Date Person the checks are for) monthiyear) Telephone Number: Address: : Please place check by the most appropriate identifier for each. Ethnicity:Hispanic or Latino Not Hispanic or Latino Race:D American Indian or Alaskan Native Asian Black or Afrian American Native Hawaian or other Pacific Islander White "By signing this proxy form I hereby acknowledge that my total household income is within the income guidelines: $23,107 for 1 person in the househod; or $31,284 for 2 people ; in the household Participant's Signature Proxy's Signature Person checks are for) Proxy Name (Print Date Address: Person picking up checks) The proxy must take this form to a distribution site in the county the participant resides in. DO NOT MAIL OFFICIAL USE ONLY Check Numbers Received: USDA Nondiscrimination Statement 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 administering USDA programs are prohibiled from discriminating based on race, color, national orign, sex, disability, age, or reprisal or retaliation for nstitutions participating in or a prior hts act it any program o activity conducted or unded by USDA Persons with disabi tes who require a ernative means o com uncation for program formation (e.g. Braille, large print, audiotape, American Sign Language, etc.) should contact the Agency (State or local) where they applied for benefts. Individuals who are deaf, hard of hearing or have speech disablities 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 Discriminaion Complaint Form, found online at http:/www.ascr.usda.gowlcomplairnt filing cust.html, and at any USDA oftice, or write a letter addressed to USDA and provide in the letter al of the informaion requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed complaint form or letter to USDA by: 1) Mail: U.S. Dept. of Agricuture, Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 2) Fax: (202) 690-7442 or 3) Emal: program.intake@usda.gov, This institution is an equal opportunity provider. II N PENNSYLVANIA BLVD I SUITE 100 WILKES-BARRE, PA wwwluzernecountyorg ; SENIOR FARMERS MARKET NUTRITION (VOUCHER) PROGRAM The Area Agency on Aging for Luzerne & Wyoming Counties announces the Distribution Schedule of the Senior Farmers Market Nutrition Vouchers provided by the United States and Pennsylvania Departments of Agriculture COMMONWEALTH OF PENNSYLVANIA | DEPARTMENT OF AGRICULTURE SENIOR FARMERS' MARKET NUTRITION PROGRAM |2019 ELIGIBILITY & PROXY FORM RIGHTS AND RESPONSIBILITIES. I have been advised of my rights and obligations under the SFMNP. lcertily that the information I have provided for my eligibility determination is correct, to the best of my knowledge. This certification form is being submitted in connecion with the receipt of Federal assistance. Program officials may verly information on this form. I understand that intentionally making a talse or misleading statement or intenticnaly misrepresenting, concealing, or withhokding facts may result in paying the Sate agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law Standards for eligibality and participation in the SFMNP are the same for everyone, regardless of race, color, national origin, age, disabiity, or sex l understand that I may appeal any decision made by the local agency regarding my ellgibiity for the SFMNP Participant Name (Print) Birthday Date Person the checks are for) monthiyear) Telephone Number: Address: : Please place check by the most appropriate identifier for each. Ethnicity:Hispanic or Latino Not Hispanic or Latino Race : D American Indian or Alaskan Native Asian Black or Afrian American Native Hawaian or other Pacific Islander White "By signing this proxy form I hereby acknowledge that my total household income is within the income guidelines: $23,107 for 1 person in the househod; or $31,284 for 2 people ; in the household Participant's Signature Proxy's Signature Person checks are for) Proxy Name (Print Date Address: Person picking up checks) The proxy must take this form to a distribution site in the county the participant resides in. DO NOT MAIL OFFICIAL USE ONLY Check Numbers Received: USDA Nondiscrimination Statement 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 administering USDA programs are prohibiled from discriminating based on race, color, national orign, sex, disability, age, or reprisal or retaliation for nstitutions participating in or a prior hts act it any program o activity conducted or unded by USDA Persons with disabi tes who require a ernative means o com uncation for program formation (e.g. Braille, large print, audiotape, American Sign Language, etc.) should contact the Agency (State or local) where they applied for benefts. Individuals who are deaf, hard of hearing or have speech disablities 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 Discriminaion Complaint Form, found online at http:/www.ascr.usda.gowlcomplairnt filing cust.html, and at any USDA oftice, or write a letter addressed to USDA and provide in the letter al of the informaion requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed complaint form or letter to USDA by: 1) Mail: U.S. Dept. of Agricuture, Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 2) Fax: (202) 690-7442 or 3) Emal: program.intake@usda.gov, This institution is an equal opportunity provider. II N PENNSYLVANIA BLVD I SUITE 100 WILKES-BARRE, PA wwwluzernecountyorg