If I am unable to pick up food, I authorize the following person(s) to pick up my CSFP food for me:

This application 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 both CSFP and WIC benefits simultaneously, and 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 to 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 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.)

The following must be read by or to the applicant before signature: • I understand that the food packages provided by this program are solely intended for my consumption as a participant in the program. I understand that selling CSFP commodities or exchanging them for non-food items could result in my termination from the program. • Improper use or receipt of CSFP benefits as a result of dual participation or other program violations may lead to a claim against me to recover the value of the benefits, and may lead to disqualification from CSFP. • I understand that I am only allowed to obtain one food package per month. I am aware that if I fail to obtain a food package during two consecutive months, my participation in the program can be terminated. • I may appeal any decision made regarding termination from the program, and I may submit a request for a fair hearing to the Community Food Bank of Eastern Oklahoma. • Nutrition education will be made available to me and I am encouraged to participate in these services. The CSFP site will provide information on other nutrition, health, or assistance programs, and make referrals as appropriate. • I consent to the release of information regarding my application to and participation in the program to CSFP staff, to other CSFP agencies if I desire to transfer to a different site, and to the officials of the USDA, Oklahoma Department of Human Services, and the Community Food Bank of Eastern Oklahoma. • I understand that I must report changes in household income or composition within 10 days after the change. • In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. I authorize the release of information 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.)

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: How to File a Complaint, 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.