Microsoft Word - Application Website English 2017.docx

LocalAgency:DeliverySite:  Date:

TO BE COMPLETED BY APPLICANT — PLEASE PRINT

Name Address

City State/ZipCode County

HomePhone



CellPhone



DateofBirth

//

PrimaryLanguage



Email



Sex

Female Male

HowdidyouhearaboutCSFP?

HOMEADDRESSVERIFIED? YesNo IDENTITYVERIFIED?YesNoType________________



HaveyoueverbeenontheCommoditySupplementalFoodProgram?YesNo

PROXY:Iauthorizethefollowingindividualstopick‐upmycommodities

intheeventthatIamunableto:

MailingAddress

(ONLYIFDIFFERENTFROM

RESIDENCE)



Address:__________________



City:_____________________



Zip:____________________

Name:____________________Name:_______________________

Relationship:________________Relationship:__________________

Phone:____________________Phone:_______________________

PROXYNOTE:SIGNATURESREQUIREDONPAGE3



RaceandEthnicData

Thisinformationisforrecordkeepingpurposesonly.Itdoesnotaffectyoureligibility.



AreyouHispanicorLatino? YesNo

Whatisyourrace? 

Asian   White BlackorAfricanAmerican

AmericanIndianorAlaskanNative NativeHawaiianorPacificIslander

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

PARTICIPANT APPLICATION

UDOH Thisinstitutionisanequalopportunityprovider. Revisedforwebsite3/2017

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:

(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:[email protected].



Thisinstitutionisanequalopportunityprovider.

IncomeVerification

Seniors(aged60yearsorolder)areincome‐eligibleforCSFPiftheirgrossincomeisatorbelow130%of

federalpovertythresholds.

MonthlyIncomeis

determinedasfollows:

WeeklyIncome(x)4.3 Semi‐monthlyIncome(2timespermonth)(x)2

Bi‐weeklyIncome(x)2.15Monthlyincome(1timepermonth)

Household

Member

Wages

SocSecIncome/

Retirement/Pension

Public

Assistance

Self

Employment

Unemployment Other

 $ $ $ $ $ $

Totalincomefromallsources: $ .00 Numberofpeoplelivinginhouse: 

Certification Statements

Bothstatementsmustbereadtoorreadbytheapplicant:

1. ThisapplicationisbeingcompletedinconnectionwiththereceiptofFederal

assistance.Programofficialsmayverifyinformationonthisform.Iamawarethat

deliberatemisrepresentationmaysubjectmetoprosecutionunderapplicable

StateandFederalstatutes.IamalsoawarethatImaynotreceivebothCSFP

and

WICbenefitssimultaneously,andImanynotreceiveCSFPbenefitsatmorethan

oneCSFPsiteatthesametime.Furthermore,Iamalsoawarethatthe

informationprovidedmaybesharedwithotherorganizationstodetectand

preventdualparticipation.Ihavebeenadvisedofmyrightsandobligations

under

theprogram.IcertifythattheinformationIhaveprovidedformyeligibility

determinationiscorrecttothebestofmyknowledge.

Pleaseindicatedecisionbyplacingacheckmarkintheappropriatebox.

1. Yes  No  Initials .

UDOH Thisinstitutionisanequalopportunityprovider. Revisedforwebsite3/2017

2. Iauthorizethereleaseofinformationprovidedonthisapplicationformtoother

organizationsadministeringassistanceprogramsforuseindeterminingmyeligibility

forparticipationinotherassistanceprogramsandforprogramoutreachpurposes.

Pleaseindicatedecisionbyplacingacheckmarkintheappropriatebox.

2. Yes  No  Initials .

Astheapplicant,orproxyfortheapplicant,IunderstandtheRightsandResponsibilitiesoftheCommodity

SupplementalFoodProgramandagree.IhavereceivedtheNoShowpolicyandunderstandthatIneedto

makearrangementstopick‐upmyboxeachmonth,ormakearrangementswiththeUtahFoodBank.Ialso

understandthatcertificationperiodsarein6monthincrements,orasotherwisestipulatedbytheUtahFood

Bank,andthatIwillneedtorecertifyfortheprogramevery6monthswhenIreceivealetterinthemail.

Signature of Applicant or Legal Guardian

Date

Signature of Proxy

Date

Signature of Proxy

Date

Mail completed application to Utah Food Bank

Utah Food Bank

ATTN: CSFP

3150 South 900 West

Salt Lake City, UT 84119

If you have further questions about the application please call Utah Food Bank at: 801-887-1275.

SUBDISTRIBUTION AGENCY USE ONLY

CopyofApplicationRights&Responsibilities

providedtoapplicantuponinitialapplication.

DistributionOfficial̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲

Identificationandaddressverified. DistributionOfficial̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲̲

UDOH Thisinstitutionisanequalopportunityprovider. Revisedforwebsite3/2017

BELOW FOR CERTIFIER USE ONLY

Persons60YearsandOlder

130%oftheFederalPovertyIncomeGuidelines–valid

March2017untilfurthernotice

Referralissuedtoparticipant?

YesWebdownload

NoShowpolicyissuedtoparticipant?

YesWebdownload

Writteninformationprovided(checkallgiven)

HealthandSocialServicesReferral

Nutrition

2‐1‐1

SNAP(FoodStamps)(SpanishorEnglish)

UtahHelps(SpanishorEnglish)

Maximumincomefora

householdof

is:

$  .00



PickUp HomeDelivery

Isthereavailablecaseload? YesNo

Clientnotifiedby: Phone  Inperson U.S.Mail

EligibleApprovedWaitlist PreApplication

Certificationperiod: to: 

by:  Date:

Signature/TitleofCertifier

PrintName:

 NotEligible dueto:



by:  Date:

Signature/TitleofCertifier

PrintName:

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 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: [email protected].

Mail completed application to Utah Food Bank 3150 South 900 West, Salt Lake City, UT 84119

Persons in Family or Household

Size Monthly

1 ............... $1,307

2 ............... $1,760

3 ............... $2,213

4 ............... $2,665

5 ............... $3,118

6 ............... $3,571

7 ............... $4,024

8 ............... $4,477

Each additional member add $453

UDOH Thisinstitutionisanequalopportunityprovider. Revisedforwebsite3/2017

Thank you for your interest in the Commodity Supplemental Food Program (CSFP). Please fill out

the following application and checklist. Please mail completed applications to the Utah Food Bank for

quicker processing. If you cannot mail the application please drop it off at the location nearest you

from the list below.

 Print all pages and fill out all the participant information on pages 1- 4.

 Photocopy ID (driver’s license or ID card) & address verification (ID card, or utility bill) if

mailing, otherwise bring originals for visual verification when you drop off your application.

 Keep and read: Applicant’s Rights & Responsibilities, No-Show Policy and Social Services

Referrals.

 Mail application pages 2-5 to the Utah Food Bank.



Adventure Church

352 West 12300 South

Draper, UT 84020

801-688-7251

Agape Community Center

765 East 100 North

Payson, UT 84651

801-885-5523

Bountiful Community Food Pantry

480 East 150 North

Bountiful, UT 84010

801-299-8464

Carbon County Food Bank

75 East 400 South

Price, UT 84501

435-637-5444

Catholic Community Services of

Northern Utah

2504 F Avenue

Ogden, UT 84401

801-394-5944

Emery County Food Bank

40 South Center Street

Castledale, UT 84513

435-381-5410

Grand County Food Bank

56 North 200 East

Moab, UT 84532

435-259-6456

Green River Community Center

125 South Long Street

Green River, UT 84525

435-564-8199

Tooele County Food Bank

38 South Main Street

Tooele, UT 84074

435-843-4764

Utah Food Bank

3150 South 900 West

Salt Lake City, UT 84119

801-887-1275

Thank you for submitting your CSFP application. You will be receiving a letter from Utah Food Bank

to update you on your application status. If you have any questions about the application or process

please call (801)887-1275.

UDOH Thisinstitutionisanequalopportunityprovider. Revisedforwebsite3/2017

Failuretocomplywiththerulesbelowmayresultindisqualificationfromparticipationinthe

CommoditySupplementalFoodProgram(CSFP).

Rights

1. StandardsforparticipationintheProgramarethesameforeveryoneregardlessofrace,

color,sex,nationalorigin,ageordisability.

2. Youmayappealanydecisionmadebythelocalagencyregardingyourdenialor

terminationfromtheProgram.Youhavearighttoafairhearing.

3. ThelocalagencywillprovidenotificationofadecisiontodenyorterminateCSFPbenefits.

Thelocalagencywillalsoprovidenoticeoftheindividual’srighttoappealthisdecisionby

requestingafairhearing.

4. Thelocalagencywillmakenutritioneducationavailabletoalladultparticipants,andto

parentsorcaretakersofinfantsandchildparticipants,andwillencouragethemto

participate.

5. Thelocalagencywillprovideinformationonothernutrition,healthorassistance

programs,andmakereferralsasappropriate.

6. ImproperuseorreceiptofCSFPbenefitsasaresultofdualparticipationorotherprogram

violationsmayleadtoaclaimagainsttheindividualtorecoverthevalueofthebenefits,

andmayleadtodisqualificationfromCSFP.

7. Participantsmustreportchangesinhouseholdincomeorcompositionwithin10daysafter

thechangebecomesknowntothehousehold.

Responsibilities

1. Donotmakefalsestatementsorallyorinwritinginordertoobtainbenefitstowhichyou

oryourhouseholdwouldnototherwisebeeligible.

2. Donotconcealinformationinordertoobtainbenefitsforwhichyouarenoteligible.

3. DonotalterProgramdocumentsforthepurposeofreceivingincreasedbenefitsforwhich

youarenoteligibleorforthepurposeoftransferringbenefitstounauthorizedindividuals.

4. Donotusesupplementalfoodsinanunauthorizedmanner,suchastradingorsellingthe

foods.

5. DonotcommitdualparticipationinCSFP(localand/orstates).

Ineligibility

IhavebeenadvisedinwritingthatIamineligibletoparticipateintheCommoditySupplemental

FoodProgramandhavetherighttoafairhearing.Iamineligibletoparticipatebasedonthe

followingcriteria:Income/HomeAddress/Category.

Right of Appeal/Fair Hearing

APPLICANT’S RIGHTS &

RESPONSIBILITIES

UDOH Thisinstitutionisanequalopportunityprovider. Revisedforwebsite3/2017

Ifyouaredissatisfiedwithanyactionorfailuretoactwithregardtoyourapplicationforthe

CommoditySupplementalFoodProgram,orwithregardtothefoodbenefitsyouarenow

receiving,orbecausesuchbenefitshavebeencancelled,youhavetherighttoappeal.(Afair

hearingneednotbegranted,however,wheneitherStateorFederallawrequiresautomaticgrant

adjustments).YoumayappealinwritingororallytothelocalofficeoftheUtahDepartmentof

Health,CommoditySupplementalFoodProgram,P.O.Box141013,SaltLakeCity,UT84114,801‐

273‐2915within30calendardaysofthedateofthisnotice.



Atthefairhearing,yourcasemaybepresentedbyyourself,ahouseholdmemberor

representative,suchaslegalcounsel,arelative,afriendorotherspokespersonyouchoose.Afair

hearingwillbeconductedbyanimpartialofficialwhowillrenderadecisionregardingyourcase.

However,therearenotprovisionswherebytheDepartmentcanpaytheattorney’sfee.



Ifyourequestafairhearingbecauseofareductionofterminationofyourbenefitswithin15

calendardaysfromthisnotice,yourbenefitswillbecontinuedatthepresentlevelatleastuntil

thetimeofthehearing.



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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:[email protected].

Thisinstitutionisanequalopportunityprovider.



UtahDepartmentofHealthContact:  UtahFoodBankContact:

AmandaDouglas,MACL DeniseNielson

ProgramCoordinator OutreachCoordinator

Phone:801‐273‐2915 Phone:801‐887‐1275

UDOH Thisinstitutionisanequalopportunityprovider. Revisedforwebsite3/2017



As part of the Commodity Supplemental Food Program (CSFP) food packages should be collected

from the designated locations every month. Each participant shall be given the time and location of

their monthly pick-up. If a participant fails to pick-up their box in a month the participant shall be

considered a “no-show.” Violation of the “no-show” policy shall result in forfeiture of CSFP benefits.

The CSFP No-Show policy is as follows:

1. Participant’s failure to pick-up food packages for two (2) consecutive months will be removed

from enrollment in CSFP.

2. Participants in hospital, out of town, or unable to pick-up the food package due to illness for

two (2) consecutive months may remain on the program and will not be removed, as long as

they contact the Utah Food Bank, (801)887-1275.

3. Participants who are removed from the program for violation of the “no-show” policy are

allowed to re-apply for benefits unless they have violated the “no-show” policy twice

previously. If a wait list exists, participants re-applying after violating the “no-show” policy

must be treated as if they were applying for the first time, and must be placed on the wait list

in the order in which they contacted the Utah Food Bank.

4. Participants who violate the “no-show” policy a third time within a twelve (12) month period

must be disqualified from CSFP for a period of up to one year, unless the local agency

determines that disqualification would result in a serious health risk.

5. Participants in violation of the “no-show” policy have a right to request a fair hearing by

contacting their local CSFP agent at (801) 273-2915. Participants have thirty days (30) from

the date of written notice to request a fair hearing.

NO-SHOW POLICY

UDOH Thisinstitutionisanequalopportunityprovider. Revisedforwebsite3/2017

2-1-1…………………………………….…………………………………………………………………………………………………………….…….……….2-1-1

Services: Information and referrals for sexually transmitted diseases, immunizations, alcohol

and drug abuse, sexual assault or rape, family violence, counseling and more.

Adult Protective Services …….……………….…….…………………………………………………………..801-538-3567

Services: Investigation into alleged abuse, neglect or exploitation of vulnerable adults over

the age of 18.

Aging Information Hotline ………………….…..…………………………………………………………..….877-424-4640

Circuit Breaker ………………………………………………..………………………………………………….……….….385-468-8300

Services: Assistance for low income seniors with the Circuit Breaker Tax Abatement

Program.

Elderly Abuse or Neglect Hotline ………………………………………………………….…………....800-371-7897

Meals on Wheels ………………………………………………………………………………………………….…..…….385-468-3220

www.aging.slco.org

Services: Home delivered meals to homebound seniors age 60+ that lack other meal

preparation resources.

Medicaid …………………………………………………………………………………………………….………………….…….…800-662-9651

Services: Medical expenses for limited income households that meet eligibility.

Medicare …………………………………………………………………………………………..…..800-MEDICARE (633-4227)

www.medicare.gov

Services: Health insurance to persons ages 65 and older.

State Energy Assistance Lifeline (SEAL)

http://jobs.utah.gov/housing/seal/

HEAT, UMP, EAF ………………………………….………………………………………………….……………800-331-4341

Services: Winter home heating assistance and year round crisis intervention.

HELP ……………………………………………………………………………………………………………………….…....801-468-0221

Services: Discounts on monthly bills for Rocky Mountain Power customers.

UTAP ………………………………………………………………………………………………………………………………800-948-7840

Services: Discounts on home landline phone service (no cell phones).

Supplemental Nutrition Program (SNAP)…………………………………………….……….866-435-7414

http://jobs.utah.gov/customereducation/services/foodstamps/

Services: “Food Stamps” for purchasing food or food products with nutritional value.

Supplemental Security Income (SSI) ……………………………………………….……………..800-772-1213

Services: Monthly benefits for those who are 65 and older, or meet other eligibility criteria.

Utah State Tax Commission (Circuit Breaker-Renters Rebate) ..801-297-2200

Services: Information and claim forms for mobile home owners and renter rebate programs.

Answers tax related questions.

SOCIAL SERVICES &

FINANCIAL ASSISTANCE REFERRALS