Apply for the CSFP

Step 1 of 5

Name (Last, Middle Initial, First)*
Last Middle Initial First
Mailing Address*
Mailing Address Address Line 2 City State ZIP Code
Do you have a different physical address?*
- Yes
- No
Physical Address
Street Address Address Line 2 City State ZIP Code
Phone*
Email
Enter Email Confirm Email

An email is not required, though if you have one we may contact you using it.
Housing Site Name

Please indicate the name of your housing site, not your name, if applicable.
I Am:*
- Male
- Female
How Old Are You?*
Please provide your age in years
Date of Birth*
Month
Day
Year

Please provide your date of birth.
Date of Birth Confirmation*
I attest that I am 60 years of age or older and a Vermont resident.
By checking above I am attesting that the date of birth provided is my legal date of birth, that I currently reside in Vermont, and I agree to provide proof if requested by Vermont Foodbank staff.

Proxy Form
This form will allow you to designate a person to pick up your CSFP food. Proxies must present appropriate identification at the time of food pick up.

Participant or Parent/Caretakers Authorization of Proxy

I hereby give permission to the person/organization listed below to pick up/accept delivery of CSFP food for me when I am unable to do so. I understand in giving permission to the person/organization below, I accept all responsibility for their actions. This authorization becomes effective when received by the CSFP program. I agree to notify CSFP promptly if I decide to make any changes in (i.e. update, add or remove) my designated proxies.

If you are a resident of a senior housing site, you must indicate the name of the facility and the facility manager and/or their designee, so the facility may sign for the food delivery to your building on your behalf. An internal schedule has been arranged at your housing location for you to pick up your food. Please contact your facility manager for more information regarding the internal schedule.
I would like to designate...*
- One person or organization to serve as my proxy.
- Two people or organizations to serve as my proxies.
- I do not wish to designate a proxy at this time.
Hidden
Proxy 1 Details
Proxy Information
Contact Name
First Last Organization
You may leave the Organization field empty if your proxy is an individual not affiliated with an organization.
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Hidden
Proxy 2 Details
Proxy Information
Contact Name
First Last Organization
You may leave the Organization field empty if your proxy is an individual not affiliated with an organization.
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone

YOUR RIGHTS AND RESPONSIBILITIES IN THE VERMONT CSFP

I AGREE TO PROVIDE:
- Proof of my income, address, and identification if requested
- Correct information about my current household and income
- Any change in my address, telephone number, income, or household composition within ten (10) days after the change becomes known to the household.
I UNDERSTAND THAT:
- Standards for participation in the Program are the same for everyone regardless of race, color, national origin, sex, age and disability.
- CSFP will provide a box of supplemental foods each month at a predetermined delivery site CSFP will provide referrals to nutrition, health, or assistance programs as appropriate CSFP will provide written nutrition education to all program participants.
- If I do not pick up food three (3) months in a row, I will be taken off of the program.
- I will be dropped from this program if I participate in another CSFP program
- Improper use or receipt of CSFP benefits as a result of dual participation or other program violations may lead to a claim against you to recover the value of the benefits, and may lead to disqualification from CSFP.
- I may appeal through the fair hearing process, any decision made by the local agency regarding denial, disqualification, or termination from the program.
CERTIFICATION

This application form 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 CSFP benefits at more than one CSFP site at the same time. Furthermore, I am 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.

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 public assistance programs and for program outreach purposes.

(Please indicate decision by placing a checkmark in the appropriate box).
Information Release*
- Yes, I authorize the release of my information.
- No, I do not authorize the release of my information.
BEFORE SIGNING, BE AWARE OF YOUR RIGHTS AND WHAT YOUR SIGNATURE MEANS

Non-discrimination Statement:

The CSFP staff at the Vermont Foodbank will review your application for eligibility. You will be notified by mail within ten (10) days if you are eligible, denied, or placed on a waiting list for entry into the program.

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, rom 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. (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. (2) fax: (202) 690-7442;
3. or (3) email: http://mailto:program.intake@usda.gov
This institution is an equal opportunity provider.
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Para todos los demás programas de asistencia de nutrición del FNS, agencias estatales o locales y sus subreceptores, deben publicar la siguiente Declaración de No Discriminación:

De acuerdo con la ley federal de derechos civiles y las normas y políticas de derechos civiles del Departamento de Agricultura de los Estados Unidos (USDA), esta entidad está prohibida de discriminar por motivos de raza, color, origen nacional, sexo (incluyendo identidad de género y orientación sexual), discapacidad, edad, o represalia o retorsión por actividades previas de derechos civiles.

La información sobre el programa puede estar disponible en otros idiomas que no sean el inglés. Las personas con discapacidades que requieren medios alternos de comunicación para obtener la información del programa (por ejemplo, Braille, letra grande, cinta de audio, lenguaje de señas americano (ASL), etc.) deben comunicarse con la agencia local o estatal responsable de administrar el programa o con el Centro TARGET del USDA al (202) 720-2600 (voz y TTY) o comuníquese con el USDA a través del Servicio Federal de Retransmisión al (800) 877-8339.

Para presentar una queja por discriminación en el programa, el reclamante debe llenar un formulario AD-3027, formulario de queja por discriminación en el programa del USDA, el cual puede obtenerse en línea en: < href="https://www.fns.usda.gov/sites/default/files/resource-files/usda- program-discrimination-complaint-form-spanish.pdf">https://www.fns.usda.gov/sites/default/files/resource-files/usda- program-discrimination-complaint-form-spanish.pdf, de cualquier oficina de USDA, llamando al (866) 632-9992, o escribiendo una carta dirigida a USDA. La carta debe contener el nombre del demandante, la dirección, el número de teléfono y una descripción escrita de la acción discriminatoria alegada con suficiente detalle para informar al Subsecretario de Derechos Civiles (ASCR) sobre la naturaleza y fecha de una presunta violación de derechos civiles. El formulario AD-3027 completado o la carta debe presentarse a USDA por:
1. correo:
  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 o (202) 690-7442; or
3. correo electrónico:
  program.intake@usda.gov
Signature of Applicant/Guardian*
Type Your Full Name
Authorization*
I agree
By reading, signing and dating this form, I acknowledge that I have been advised of my rights and obligations under the program. I attest that the information provided is accurate and complete to the best of my knowledge.
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Apply for the CSFP

Step 1 of 5

Income Eligibility

CSFP Income Eligibility Requirements

Income Specifics

USDA Statistical Information

Data in this section is a USDA statistical requirement for the program. Responses will not affect consideration of this application.

Proxy Form

Participant or Parent/Caretakers Authorization of Proxy

Proxy 1 Details

Proxy Information

Proxy 2 Details

Proxy Information

YOUR RIGHTS AND RESPONSIBILITIES IN THE VERMONT CSFP

I AGREE TO PROVIDE:

I UNDERSTAND THAT:

CERTIFICATION

BEFORE SIGNING, BE AWARE OF YOUR RIGHTS AND WHAT YOUR SIGNATURE MEANS

Non-discrimination Statement: