SFMNP Form 2025
Senior Farmers’ Market Nutrition Program (SFMNP) Form for 2025
Certify following are true and correct:
  1. I am at least 60 years of age.
  2. I reside in the county where I am requesting to receive food coupons.
  3. I am making only one request for ten SFMNP food coupons for the 2025 program year.
  4. I meet the maximum annual household income requirement stated here: $33,282 - 1 person, $44,992 - 2 persons, add $11,711 per additional household member (including children).

* Email: If you do not have an email, include friend or relative to contact you.
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Email *
Application Date
 *
MM
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DD
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Last Name *
First Name *
Sex *
Date of Birth *
MM
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DD
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YYYY
Household size *
Annual Income (whole dollar) *
Mailing Address
City
State
Zip Code (number)
Telephone Number
                                            DESIGNATION OF PROXY (Optional)
A "Proxy" or "authorized representative" is someone authorized by an eligible participant to act on the participant's behalf, including submission of application for participation, receipt  of coupons, and use of SFMNP coupons at authorized outlets as long as  the SFMNP benefits are ultimately received by the eligible senior. If you want your coupons mailed to your proxy instead of yourself, insert proxy's contact information here:
Proxy Name (Last, First)
Proxy Relation
Proxy Telephone Number
Proxy Address (Include City, State, Zip Code)
                                                       ETHNIC BACKGROUND
USDA requires the State to obtain race and ethnic  information. This information is solely for the purpose of determining  the State's compliance with Federal civil rights laws. Your response  will  not affect consideration of you application.
Ethnic Background: Do you consider yourself Hispanic or Latino? *
Ethnic Background *
Check all that apply
Required
Certification Statement
I have been advised of my rights and obligations under the SFMNP. I certify 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 connection with the receipt of Federal assistance. Program officials may verify 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 improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law. Standards of eligibility and participation in the SFMNP are the same for everyone, regardless of race, color, national origin, disability, or sex. I understand that I may appeal any decision made by the local agency regarding my eligibility for the SFMNP.
I agree *
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies,  this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior  civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require  alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by:
1. mail:
   U.S. Department of Agriculture
   Office of the Assistant Secretary for Civil Rights
   1400 Independence Avenue, SW
   Washington, D.C. 20250-9410; or
2. fax:
   (833) 256-1665 or (202) 690-7442; or
3. email:
   program.intake@usda.gov

This institution is an equal opportunity provider.

05/05/2022    
https://www.fns.usda.gov/civil-rights/usda-nondiscrimination-statement-other-fns-programs
A copy of your responses will be emailed to the address you provided.
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