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.