SFMNP- We are working on the "Senior Farmers' Market Nutrition Program" differently this year.
We are making the form available online and in our newsletter. Please fill out the form and mail or email it to our office. You can download and fill out and attach to an email or you can print and mail it into our office.
Pike County AAA
150 Pike County Blvd.,
Lords Valley, PA 18428
or email to:
once we receive/review it, we will send out the vouchers.
Due to the Covid -19 Pandemic, please do not come to the office to pick them up.
Please read USDA Nondiscrimination Statement -
USDA Nondiscrimination Statement
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: 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: email@example.com.
This institution is an equal opportunity provider.
This is the Application Form for the Famers Market Vouchers also. This s a downloadable document you can print and fill out.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF AGRICULTURE
SENIOR FARMERS’ MARKET NUTRITION PROGRAM
2020 Application Form
To qualify you must be 60 or older (or turn 60 by 12/31/2020) and meet the household income guidelines.
RIGHTS AND RESPONSIBILITIES
I certify that the information I have provided below for my eligibility determination is correct, to the best of my knowledge. This certification form is being submitted in connection with the 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 paying the State agency, 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.
Standards for eligibility and participation in the SFMNP are the same for everyone, regardless of race, color, national origin, age, disability, or sex.
I understand that I may appeal any decision made by the local agency regarding my eligibility for the SFMNP.
By signing this, I acknowledge that my total household income is within the Income guidelines: $23,606 for 1 person in the household; or $31,894 for 2 people in the household and that I am 60 years old or older (or will turn 60 by December 31, 2020).
1st Participant Name (print): Birth date ________________ (Person checks are for)
2nd Participant Name (print): Birth Date ________________ (Person checks are for)
Telephone Number: County you live in _______________________________
Please circle the most appropriate identifier for each:
Ethnicity: Hispanic or Latino Not Hispanic or Latino
Race: American Indian or Alaskan Native Asian Black or African American
Native Hawaiian or other Pacific Islander White
If more responses are received than funding allows you will be notified by mail.
Please mail or email your completed form before September 30, 2020 to:
Pike County Area Agency on Aging - 150 Pike Co. Blvd - Lords Valley, PA 18428
or email to: firstname.lastname@example.org