Osage Nation Senior Farmers' Market Nutrition Program Application

Only one person per form submission. Each eligible WIC participant in your household needs to fill this application out separately.

Requirements:

Requirements: Must meet income guidelines

Click here for income guidelines
Additional Requirements:
Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Authorized Rep (if any) Authorized Rep (if any) First Last
You may authorize 1 person to pick up and use coupons/vouchers for you.
Number in Household:
Gross Household Income:
per
Check all that apply

Check all that apply I receive, or am eligible for SNAP (food stamps) I receive Medicaid I receive Supplimental Security Income (SSI) I receive commodities from Food Distribution
Ethnicity
Race (check all that apply)

Race (check all that apply) Asian White Black or African American Native Hawaiian or Other Pacific Islander Other Prefer Not to Answer American Indian/Alaska Native - Tribal Affiliation:
Read and select the program guidelines if you:

Read and select the program guidelines if you: Have read on the ON Website the list of Farmer's and Farmers' Market location. Understand what fruits and vegetables you can receive. Understand how to use your coupon/voucher(s). Understand you DO NOT have to redeem the full amount of the coupon/voucher(s). Understand Farmers/Farmers' Markets do not owe you change if you do not redeem the full $5.00. Understand coupon/voucher(s) cannot be traded for money. Understand that you must sign coupon/voucher(s) in front of Farmer/Farmers' Market sales person. Understand that Farmers/Farmers' Markets should not charge tax on coupon/voucher(s). Will receive nutrition education when I receive my coupon/voucher(s).
Program Guidelines

Program Guidelines I have read and understood the above program guidelines.
Rights and Responsibilities

Rights and Responsibilities I have read the rights and responsibilities under the program.
I certify that the information I have provided for my eligibility is correct to the best of my knowledge. I affirm that I meet the minimum requirements for participation in the Senior's Farmers' Market Nutrition Program.
Applicant's Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
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 institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities 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 Discrimination Complaint Form, (AD-3027) found online at: How to File a Complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

Mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410

Fax: (202) 690-7442

Email: program.intake@usda.gov

Osage Nation Senior Farmers' Market Nutrition Program Application

Osage Nation Senior Farmers' Market Nutrition Program Application

I certify that the information I have provided for my eligibility is correct to the best of my knowledge. I affirm that I meet the minimum requirements for participation in the Senior's Farmers' Market Nutrition Program.