SENIOR FARMERS’ MARKET NUTRITION PROGRAM
SELF DECLARATION FORM
_
Participation in the Senior Farmers’ Market Nutrition Program is limited to those senior citizens
who are 60 years and older and whose gross income (i.e., income before deductions for income
taxes, Social Security taxes, insurance premiums, bonds, etc.) is equal to or less than the income
poverty guidelines increased by 185%.
Senior Farmers' Market Nutrition Program Income
Eligibility Guidelines
(Effective from July 1, 2020 to June 30,
2021)
48 Contiguous States, D.C., Guam and Territories
Household Size
1
8
5
%
Annual
Monthly
Twice Monthly Biweekly
Weekly
1
$23,606
$1,968
$984
$908
2
31,894
2,658
1,329
1,227
3
40,182
3,349
1,675
1,546
4
48,470
4,040
2,020
1,865
5
56,758
4,730
2,365
2,183
6
65,046
5,421
2,711
2,502
7
73,334
6,112
3,056
2,821
8
81,622
6,802
3,401
3,140
Each add'l fam mem
add
+ $8,288
+ $691
+ $346
+ $319
My signature indicates that I have reviewed the income guidelines by household. By signing this I
attest that my income is at or below my household size, listed above. I also affirm that I live in
County and I am at least 60 years of age. I understand that if any of these statements
are
found to be fraudulent, I will be subject to sanctions per the State Policies and Procedures.
Printed Name of Participant/Proxy Date
Signature of Participant/Proxy
Select
click to sign
signature
click to edit
SENIOR FARMERS’ MARKET NUTRITION PROGRAM
SELF DECLARATION FORM
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.
file a program complaint of discrimination, complete the USDA Program
DiscriminationComplaint Form, (AD-3027) found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, 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:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3) email:program.intake@usda.gov.
This institution is an equal opportunity provider.
http://www.fns.usda.gov/wic/wic-income-eligibility-guidelines
USDA is an Equal Opportunity Provider, Employer and Lender
Federal Register / Vol. 84, No. 81 / Friday , April 26, 2019 / Notices