1) To report any changes in residence within 10 days.
2) To report any changes to my household size within 10 days.
3) To report any changes in my shelter/utility expenses within 10 days.
4) To report any changes or increase in gross monthly income over $100 within 10 days.
5) To report any changes in a household member's obligation to pay child support within 10 days.
6) It is prohibited to receive both SNAP (food stamps) or FDPIR benefits within the same month.
7) It is prohibited to give any false or misleading information to receive food distribution benefits.
8) It is prohibited to barter/trade or sell my household's food distribution benefits. Initials: _________
FAIR HEARING: If you disagree with any action taken on your case, you and/or your representative have the right to request
a fair hearing. You may request a fair hearing verbally or in writing. If you request a fair hearing, your case may be presented
by a member of your household or representative, such as a legal counsel, a relative, a friend or other spokesperson.
2) Fax: (202) 690-7442; or
This institution is an equal opportunity provider.
INTENTIONAL PROGRAM VIOLATION (IPV) PENALTIES:
If you or a household member knowingly/willingly violate the rules
initialized above, it is considered an Intentional Program Violation (IPV). Households who have been found guilty of committing
an IPV will be ineligible to participate in both FDPIR and SNAP programs for a period of twelve (12) months for the first
violation, 24-months for the second violation and permanently for the third violation; even prosecuted by authorities.
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, religious creed, disability, age, political beliefs, 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: 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:
RULES OF UNDERSTANDING: By my initials below I understand and agree to the following eight (8) rules:
Mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
FORM: FDP001 Page 5 Revised: October 2019