Have you applied for your Senior Farmers Market Nutrition Checks? IF YOU HAVE NOT RECEIVED CHECKS THIS YEAR AND YOU MEET THE QUALIFICATIONS APPLY LAST DAY TO ISSUE CHECKS IS SEPT. 29 - LAST DAY TO USE CHECKS IS NOV. 30 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF AGRICULTURE SENIOR FARMERS' MARKET NUTRITION PROGRAM 2023 APPLICATION FORM FOR LUZERNE AND WYOMING COUNTY AM TO QUALIFY, YOU MUST BE 60 OR OLDER (OR TURN 60 BY 12/31/2023) 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: $26,973 for 1 person in the household; or $36,482 for 2 people in the household and that I am 60 years old or older (or will turn 60 by 12/31/23). ONLY 1 SET OF VOUCHERS PER PERSON IS ALLOWED. 1st Participant Name (Print): Signature 2nd Participant Name (Print): Signature Address (Print): Telephone Number: Please circle appropriate identifier: Hispanic or Latino Ethnicity: Race: American Indian or Alaskan Native Native Hawaiian or other Pacific Islander (Person checks are for) Signature (Person checks are for) Signature Asian White County of Residence: Not Hispanic or Latino Black or African American Birth Date Birth Date * MUST COMPLETE ALL LINES Please mail or drop off your completed form before September 29, 2023 to: Area Agency Aging for Luzerne & Wyoming Counties, 93 North State Street, Wilkes Barre, PA 18701 OR EMAIL: AAA-Farmers-Market@luzernecounty.org Have you applied for your Senior Farmers Market Nutrition Checks ? IF YOU HAVE NOT RECEIVED CHECKS THIS YEAR AND YOU MEET THE QUALIFICATIONS APPLY LAST DAY TO ISSUE CHECKS IS SEPT . 29 - LAST DAY TO USE CHECKS IS NOV . 30 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF AGRICULTURE SENIOR FARMERS ' MARKET NUTRITION PROGRAM 2023 APPLICATION FORM FOR LUZERNE AND WYOMING COUNTY AM TO QUALIFY , YOU MUST BE 60 OR OLDER ( OR TURN 60 BY 12/31/2023 ) 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 : $ 26,973 for 1 person in the household ; or $ 36,482 for 2 people in the household and that I am 60 years old or older ( or will turn 60 by 12/31/23 ) . ONLY 1 SET OF VOUCHERS PER PERSON IS ALLOWED . 1st Participant Name ( Print ) : Signature 2nd Participant Name ( Print ) : Signature Address ( Print ) : Telephone Number : Please circle appropriate identifier : Hispanic or Latino Ethnicity : Race : American Indian or Alaskan Native Native Hawaiian or other Pacific Islander ( Person checks are for ) Signature ( Person checks are for ) Signature Asian White County of Residence : Not Hispanic or Latino Black or African American Birth Date Birth Date * MUST COMPLETE ALL LINES Please mail or drop off your completed form before September 29 , 2023 to : Area Agency Aging for Luzerne & Wyoming Counties , 93 North State Street , Wilkes Barre , PA 18701 OR EMAIL : AAA-Farmers-Market@luzernecounty.org