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    May 23, 2021
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SENIOR FARMERS MARKET NUTRITION (VOUCHER) PROGRAM The Area Agency on Aging for Luzerne & Wyoming Counties will be holding the annual distribution of the Senior Farmers Market Nutrition Program (SFMNP) vouchers provided by the United States and Pennsylvania Departments of Agriculture. During the COVID-19 pandemic, it is the Departments top priority to ensure seniors can receive the SFMNP vouchers without fear of being exposed and, for this reason, the voucher distribution this year will be done completely by mail. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF AGRICULTURE SENIOR FARMERS' MARKET NUTRITION PROGRAM 2021 APPLICATION FORM FOR OFFICE USE ONLY APPLICATION TO QUALIFY YOU MUST BE 60 OR OLDER (OR TURN 60 BY 12/31/2021) AND MEET THE HOUSEHOLD INCOME GUIDELINES RIGHTS AND RESPONSIBILITIES: I certity that the information I have provided below tor my eligibility determination is correct, to the best of my knowledge. This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verity information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the State agency, in cash, the value of the food benefits improperty issued to me and may subject me to civil or criminal prosecution under State and Federal law. Standards for eligibility and participation in the SFMNP are the same for everyone, regardless of race, color, national origin, age, disability, or sex. I understand that I may appeal any decision made by the local agency regarding my eligibility for the SFMNP. By signing this, I acknowledge that my total household income is within the Income guidelines: $23,828 for 1 person in the household; or $32,227 for 2 people in the household and that I am 60 years old or older (or will turn 60 by December 31, 2021). 1st Participant Name (Print): Birth Date (Person checks are for) Signature 2nd Participant Name (Print): Birth Date (Person checks are for) Signature Address (Print): Telephone Number: County You Live In: Please circle the most appropriate identifier for BOTH ethnicity AND race: Ethnicity: Hispanic or Latino Not Hispanic or Latino Race: American Indian or Alaskan Native Native Hawaian or other Pacific Islander Asian White Black or African American If more responses are received than funding allows, you will be notified by mail. Please mail or email your completed form before September 15, 2021 to: Area Agency Aging for Luzerne & Wyoming Counties, 93 North State Street, Wilkes Barre, PA 18701 or Karen.Pietraccini@luzernecounty.org. THIS INSTITUTION IS AN EQUAL OPPORTUNITY PROVIDER. 93 NORTH STATE STREET| WILKES-BARRE, PA | wwwluzernecounty.org SENIOR FARMERS MARKET NUTRITION (VOUCHER) PROGRAM The Area Agency on Aging for Luzerne & Wyoming Counties will be holding the annual distribution of the Senior Farmers Market Nutrition Program (SFMNP) vouchers provided by the United States and Pennsylvania Departments of Agriculture. During the COVID-19 pandemic, it is the Departments top priority to ensure seniors can receive the SFMNP vouchers without fear of being exposed and, for this reason, the voucher distribution this year will be done completely by mail. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF AGRICULTURE SENIOR FARMERS' MARKET NUTRITION PROGRAM 2021 APPLICATION FORM FOR OFFICE USE ONLY APPLICATION TO QUALIFY YOU MUST BE 60 OR OLDER (OR TURN 60 BY 12/31/2021) AND MEET THE HOUSEHOLD INCOME GUIDELINES RIGHTS AND RESPONSIBILITIES: I certity that the information I have provided below tor my eligibility determination is correct, to the best of my knowledge. This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verity information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the State agency, in cash, the value of the food benefits improperty issued to me and may subject me to civil or criminal prosecution under State and Federal law. Standards for eligibility and participation in the SFMNP are the same for everyone, regardless of race, color, national origin, age, disability, or sex. I understand that I may appeal any decision made by the local agency regarding my eligibility for the SFMNP. By signing this, I acknowledge that my total household income is within the Income guidelines: $23,828 for 1 person in the household; or $32,227 for 2 people in the household and that I am 60 years old or older (or will turn 60 by December 31, 2021). 1st Participant Name (Print): Birth Date (Person checks are for) Signature 2nd Participant Name (Print): Birth Date (Person checks are for) Signature Address (Print): Telephone Number: County You Live In: Please circle the most appropriate identifier for BOTH ethnicity AND race: Ethnicity: Hispanic or Latino Not Hispanic or Latino Race: American Indian or Alaskan Native Native Hawaian or other Pacific Islander Asian White Black or African American If more responses are received than funding allows, you will be notified by mail. Please mail or email your completed form before September 15, 2021 to: Area Agency Aging for Luzerne & Wyoming Counties, 93 North State Street, Wilkes Barre, PA 18701 or Karen.Pietraccini@luzernecounty.org. THIS INSTITUTION IS AN EQUAL OPPORTUNITY PROVIDER. 93 NORTH STATE STREET| WILKES-BARRE, PA | wwwluzernecounty.org