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2022 Farmers Market Check Application

Please complete and sign the application. All information must be completed and the form must be signed to be processed; any missing information will delay the processing of your form. Married couples only need to submit one application that includes information for both individuals and both individuals must sign. If your application is approved, the Farmers’ Market Program vouchers will be mailed to you.

Please Note: If your name and information is not in our database, you will be contacted by a
Blair Senior Services’ employee requesting the last four digits of your Social Security number. 

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF AGRICULTURE

SENIOR FARMERS’ MARKET NUTRITION PROGRAM

2022 Application Form

To qualify you must be 60 or older (or turn 60 by 12/31/2022) and meet the household income guidelines.

RIGHTS AND RESPONSIBILITIES

     I certify that the information I have provided below 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 for eligibility and participation in the SFMNP are the same for everyone, regardless of race, color, national origin, age, disability, or sex.
     I understand that I may appeal any decision made by the local agency regarding my eligibility for the SFMNP.

By signing this, I acknowledge that my total household income is within the Income guidelines: $25,142 for 1 person in the household; or $33,874 for 2 people in the household and that I am 60 years old or older (or will turn 60 by December 31, 2022).

Nondiscrimination Statement

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: program.intake@usda.gov.
This institution is an equal opportunity provider.

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