Virginia Senior Farmers Market Nutrition Program (SFMNP)                                       
Arlington Application 2020    
          


A completed application must received before August 3, 2020.  Coupons are limited and are distributed on a first come, first served basis. 
  
 All completed applications will be reviewed for eligibility and coupons for approved applications are mailed within 10 days of receipt of application.

Applicant                                                                      
Second Applicant
 Same Household Unit
Applicant
Ethnicity: Mark one, Regardless of Race

Race:
Mark one or more


Second Applicant
Ethnicity: Mark one, Regardless of Race

Race:
Mark one or more

Ques
tions for the 2020 Farmers Market Season

Which shopping options would you use (select all that you would use):

                                                            Virginia Senior Farmers Market Nutrition Program (SFMNP)
                                                        Arlington Application 2020

                                                                                                                       Self-Declaration for Income Eligibility
                                                                             Certification -  By my signature below I certify that

I understand that it is unlawful to receive farmer's market checks from more than one locality or to enroll in this program more than one time each Market Season.


I have been advised of my rights and obligations under the SFMNP.  I certify that the information I have provided for my eligibility determination is correct, to  the best of my knowledge.  This certification form is being submitted in connection with 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 my repaying the Virginia Department for the Aging, 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.

I understand the Program’s household income eligibility guidelines or have had them explained to me.  I hereby acknowledge with my signature that my household family income is within the published income eligibility guidelines for participation in SFMNP.


I understand that I may appeal any decision made by the local agency regarding my eligibility for the SFMNP.  Submit your written appeal to: Arlaaa@arlingtonva.us or mail to Attn: Senior Farmer's Market Program: 2100 Washington Blvd.  4th Fl. Arlington, VA 22204.

If you have completed  the application and read the rules please click below in the check box.  This check box will serve as your signature.
Then click on "Submit" button.