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Commonwealth of Pennsylvania Department of Agriculture Senior Farmers' Market Nutrition Program Application (do not delete - form unpublished seasonally)

  1. Area Agency on Aging Logo
  2. To qualify you must be 60 or older or turn in by 12/31/2022) and meet the household income guidelines:

    1 person $25,142
    2 people $33,874
    3 people $42,60
    4 people $51,338
    5 people $60,070
    6 people $68,802

  3. RIGHTS AND RESPONSIBILITIES: I certify that the information I have provided below for my eligibility determination is correct, the the best of my knowledge. This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify informaton 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, tha value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under State and Federal law.
  4. Standards for eligibility and participation in the SFMNP are the same for everyone, regardless of race, color, national origin, age, disability or sex.
  5. I understand that I may appeal any decision made by the local agency regarding my eligibility for the SFMNP.
  6. By signing this, I acknowledge that my total household income is within the Income guidelines and that I am 60 years old or older (or will turn 60 by December 31, 2022).
  7. Add 2nd Participant?
  8. Ethnicity:
  9. Race:
  10. Your electronic signature below indicates your agrement with the following statements: By typing my name in the following box I certify the above statements to be true and correct to the best of my knowledge, information, and belief.
  11. If more responses are received than funding allows you will be notified by mail. Forms must be completed by September 15, 2022.
  12. Leave This Blank:

  13. This field is not part of the form submission.