2018 Senior Farmers Market Nutrition Program Application Handout

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1 Department of Labor and Industrial Relations, Office of Community Services 2018 Senior Farmers Nutrition Program Application Handout The Seniors Farmers Nutrition Program (SFMNP) provides low-income seniors with eligible fresh produce with the goal of improving their health and nutritional status. Each SFMNP participant will receive a book of coupons worth $50.00 (ten $5.00 coupons) to exchange for fresh, nutritious, and unprocessed locally grown fruits, vegetables, herbs, and honey from an authorized farmer, farmers market, or roadside stand (outlet). How SFMNP Works 1. Apply. Complete the enclosed SFMNP Application Form for each person in the household that qualifies for SFMNP benefits. Applicants must be certified to participate each year. Forms must be received in the Office of Community Services by Friday, September 21, The eligibility requirements are: Categorical Maximum Annual Household Income Residency At least 60 years old OR Native American 55 years or older OR Disabled Individual less than 60 years old of age who is currently living in housing facilities occupied primarily by older individuals where congregate nutrition services are provided. $25,826 One Person $35, Two Persons Add $9, per additional household member (including children) Must reside in the county of service area applying to 2. Qualify. Qualified participants will be sent a coupon booklet and a coupon handout, inclusive of a schedule of outlets where the coupons can be used. 3. Shop. a. SFMNP coupons must be used by September 30, b. Only SFMNP participants or authorized representatives (proxy) may use the SFMNP coupons. A proxy must have been designated on the enclosed SFMNP Application Form. c. Bring the coupon booklet to the farmers market listed on the schedule of SFMNP farmers market. d. Authorized outlets will have a sign showing that they will accept SFMNP coupons. e. No cash change may be given. Please try to use the full $5.00 amount of each coupon. FOR MORE INFORMATION OR ASSISTANCE, PLEASE CONTACT YOUR LOCAL AGENCY: Hawaii County Economic Maui Economic Hawaii Foodbank, Inc. Opportunity Council Opportunity Hawaii Foodbank - Kauai 2611 Kilihau Street 47 Rainbow Drive 99 Mahalani Street 4241-A Hanahao Place Honolulu, Hawaii Hilo, Hawaii Wailuku, Hawaii Lihue, Hawaii (808) /(808) (808) (808) (808) State of Hawaii Department of Labor and Industrial Relations Office of Community Services 830 Punchbowl Street, Room 420 Honolulu, Hawaii Call: (808) dlir.ocs@hawaii.gov Web: labor.hawaii.gov/ocs

2 SFMNP RIGHTS AND RESPONSIBILITIES Your Rights As an applicant/participant of SFMNP you have the following rights to: Be treated with dignity, respect, and without discrimination. Be notified in writing, within 15 days of applying, if you are not determined eligible. Appeal an ineligibility decision if you feel that determination was made in error. Have information you provided kept private unless you request for it to be shared. Make a complaint if you feel you have not been treated fairly. Have clear directions of how and where to use the coupons you receive. Learn about other services that may be available to you. You may contact your local agency for services in your area. File a complaint with your local agency about improper farmer or farmers market program practices. Your Responsibilities As an applicant/participant of SFMNP you have the following responsibilities: Provide correct information, to the best of your knowledge, to determine eligibility. Understand that giving false information and/or intentionally concealing facts could result in your paying back benefits or legal action. Understand that attempting to collect benefits more than once or at multiple distribution sites during a season will result in termination from the program. Consume the fresh produce obtained through this program yourself. Safeguard the coupons you receive. Please report if they are lost or stolen (phone: (808) ; dlir.ocs@hawaii.gov). Lost or stolen coupons will not be replaced. Redeem your coupons with an authorized outlet by September 30, Understand that funding is limited for this program and on a first come, first served basis, subject to the availability of funding. 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) 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) 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 ; (2) Fax: (202) ; or (3) program.intake@usda.gov. This institution is an equal opportunity provider.

Please read this application, the accompanying application handout, and print or type clearly. For Official Use Only: Coupon # Hawaii County Economic Opportunity Council Maui Economic Opportunity Inc.

health and nutritional status. Applicants must be certified to participate each year. The number of participants is limited and on a first-come, first-serve basis.

3 Please read this application, the accompanying application handout, and print or type clearly. For Official Use Only: Coupon # Hawaii County Economic Opportunity Council Maui Economic Opportunity Inc Senior Farmers Nutrition Program (SFMNP) Application Form The Senior Farmers Nutrition Program (SFMNP) provides low-income seniors with eligible fresh produce with the goal of improving their health and nutritional status. Applicants must be certified to participate each year. The number of participants is limited and on a first-come, first-serve basis. DEADLINE: Applications must be RECEIVED by Friday, September 21, Please mail completed application to: Department of Labor and Industrial Relations Office of Community Services 830 Punchbowl Street, Room 420 Honolulu, Hawaii I am a resident of and applying for SFMNP benefits in the county of: Hawaii Honolulu/Oahu Kauai Maui Please check if applicable: I have not previously applied for Senior Farmers benefits in Name (Last, First, M.I.) Male Female Date of Birth (MM/DD/YYYY) Eligibility Criteria - Please check all that apply: I am at least 60 years of age I am a Native American at least 55 years of age I am a disabled individual less than 60 years old and living in a housing facility occupied primarily by older individuals where congregate nutrition services are provided. Maximum Annual Household Income Eligibility Requirement - Please check if applicable to your household income My household income is less than 185% of the U.S. Poverty Rate of Hawaii Less than $25,826 for a one person household Less than $35, for a two person household For each additional person, add $9, per additional household member (including children) Residential Address (Including unit #) City, Zip Code Mailing Address (Incl unit #), if different from above City, Zip Code Address Telephone Number PLEASE TURN OVER TO COMPLETE APPLICATION

4 ETHNIC BACKROUND USDA requires the State to obtain race and ethnic information. This information is requested solely for the purpose of determining the State s compliance with Federal civil rights laws. Your response will not affect consideration of your application. Please check one: Do you consider yourself Hispanic or Latino? Yes No Please check all that apply: American Indian or Alaskan Native Black or African American Native Hawaiian or Other Pacific Islander Asian White PROXY A proxy or authorized representative is defined as an individual authorized by an eligible participant to act on the participant s behalf, including submission of application for certification, receipt of SFMNP coupons or other benefits, or use of SFMNP coupons at authorized outlets as long as the SFMNP benefits are ultimately received by the eligible senior. I hereby authorize the following individual to act as my authorized representative for the SFMNP to submit my application for certification, receive my SFMNP coupons or other benefits, or shop at a farmers market on my behalf. Proxy Name (Last, First, M.I) Relationship Proxy Phone Number ( ) Certification Statement 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 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 form, I certify that I meet all of the categorical, income, and residency eligibility requirements; have and will not apply for SFMNP benefits in another county service area, acknowledging it is illegal to partake in dual participation; and acknowledge that I have been given SFMNP Rights and Responsibility information. Applicant Signature Date (MM/DD/YY) FOR MORE INFORMATION OR ASSISTANCE, PLEASE CONTACT YOUR LOCAL AGENCY: Hawaii County Economic Maui Economic Hawaii Foodbank, Inc. Opportunity Council Opportunity Hawaii Foodbank - Kauai (808) /(808) (808) (808) (808) DEADLINE: Applications must be RECEIVED by Friday, September 21, Please mail completed application to: Department of Labor and Industrial Relations Office of Community Services 830 Punchbowl Street, Room 420 Honolulu, Hawaii 96813

5 SFMNP Farmers Schedule s are CLOSED on all City Holidays Farmers Name Location Day Time Manoa Valley District Park 2721 Kaaipu Ave. Mondays 6:45a.m. 7:45a.m. Makiki District Park 1527 Keeaumoku St. Mondays 8:30a.m. 9:30a.m. Ala Moana (Magic Island) 1201 Ala Moana Blvd. Mondays 10:00a.m. 11:00a.m. City Hall Parking Lot Deck Alapai and Beretania St. Mondays 11:45a.m. 12:30p.m. Waiau District Park Komo Mai Dr. Tuesdays 6:30a.m. 7:30a.m. Waipahu District Park Paiwa St. Tuesdays 8:15a.m. 9:15a.m. Wahiawa District Park N. Cane St. and California Ave. Tuesdays 10:00a.m. 11:00a.m. Mililani District Park Lanikuhana Ave. Tuesdays 11:45a.m. 12:30p.m. Makeke Iki Waianae Coast Comprehensive Health Center Farrington Hwy. Tuesdays 10:00a.m. 1:00p.m. Kapiolani Community College 4303 Diamond Head Rd. Tuesdays 4:00p.m. 7:00p.m. Fort Street Mall Farmers Fort Street Mall Tuesdays and Fridays 7:00a.m. 1:30p.m. Manoa Farmers 2753 Woodlawn Dr. Tuesdays and 7:00a.m. 3:30p.m. Farmers Windward Mall by Nalo Farms Makeke Palolo Valley District Park 2007 Palolo Ave. Old Stadium Park 2237 South King St. Queen Kapiolani Park Monsarrat and Paki St. Aloha Tower 1 Aloha Tower Dr. Neal Blaisdell Concert Hall 777 Ward Ave. 6:30a.m. 7:30a.m. 8:15a.m. 9:15a.m. 10:00a.m. 11:00a.m. 11:00a.m. 1:30p.m. 4:00p.m. 7:00p.m. Windward Mall 2:30p.m. 7:00p.m. Waimanalo Beach Park Kalanianaole Hwy. Kailua District Park 21 South Kainalu Dr. Kaneohe District Park Keaahala Rd. Kapolei High School Kapolei Parkway 609 Kailua Rd. Behind Longs on Kailua Rd. 7:15a.m. 8:15a.m. 9:00a.m. 10:00a.m. 10:45a.m. 11:45a.m. 3:00p.m. 6:30p.m. 5:00p.m. 7:30p.m. Haleiwa Farmers Kamehameha Hwy. 2:00p.m. 6:00p.m. Makiki Farmers 1515 Wilder Ave. 4:30p.m. 7:30p.m.

6 Waialua Peoples Kealohanui St. Halawa District Park Iwaiwa St. Fridays Ewa Beach Community Park North Rd. Fridays Pokai Bay Beach Park Pokai Bay Rd. Fridays Kamehameha Community Park 1400 Kalihi St. Kalaukaua District Park Intersection of Kaumualii St. & 700 Kalihi St. Kalihi Valley District Park 1911 Kam IV Rd. Makeke Waianae Waianae Mall behind Pizza Hut Farrington Hwy. Salt Lake Municipal Lot 5337 Likini St. Hawaii Kai Park-n-Ride 300 Keahole St. Kapiolani Community College 4303 Diamond Head Rd. Kakaako Farmers 333 Ward Ave. Ward Gateway by Ross 4:30p.m. 7:00p.m. 8:30a.m. 2:00p.m. 7:00a.m. 8:00a.m. 9:00a.m. 10:00a.m. 11:00a.m. 11:45a.m. 6:30a.m. 7:30a.m. 8:15a.m. 9:30a.m. 10:00a.m. 10:45a.m. 8:00a.m. 12:00p.m. 11:15a.m. 12:00p.m. 1:00p.m. 2:00p.m. 7:30a.m. 11:00a.m. 8:00a.m. 12:00p.m. North Shore Country Sunset Beach Elementary School 8:00a.m. 2:00p.m. Pearlridge Farmers Pali Momi St. 8:00a.m. 12:00p.m. Farmers Windward Mall by Nalo Farms Kapolei Community Park Kamaaha Lp. Royal Kunia Park-n-Ride Kupuna Lp./Kupuohi St. Waikele Community Park Lumiaina St. Mililani High School Meheula Pkwy. 7:00a.m. 8:30a.m. 9:30a.m. 11:00a.m. 11:30a.m. 12:30p.m. 8:00a.m. 11:00a.m. Windward Mall 10:00a.m. 2:00p.m. 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) 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) 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 ; (2) Fax: (202) ; or (3) program.intake@usda.gov. This institution is an equal opportunity provider.

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