SFMNP Form

Senior Farmers Market Nutrition Program Form

The Senior Farmers Market Nutrition Program (SFMNP) provides a one-time $50 EBT debit card to eligible seniors. The card expires October 31, 2026. You must reapply each year to receive your card.

Eligibility
SFMNP Form
T&C
Summary

Senior Farmers Market Nutrition Program Form

Assessment Information

First Name

Last Name

Middle Initial

Date of Birth

Last 4 of your SSN

Street Address

City

State

ZIP Code

Is your Street Address different from your Mailing Address?

Yes

Primary Phone Number

Secondary Phone Number

Are you currently receiving SNAP (or food stamp) Benefits? (The answer to this question will not affect your eligibility for the SFMNP. This is a separate benefit card.)

Yes

Your household size?

Gross Household Income

Income Frequency

How often do you receive your indicated gross household income?

How did you hear about this program?

Select all that apply:

American Indian or Alaskan Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Pacific Islander

Other

Prefer not to say

White

I acknowledge I am only able to participate in one Senior Farmers Market Nutrition Program per market season. (This includes tribal Senior Farmers Market Nutrition Programs.)

Senior Farmers Market Nutrition Program Form

Terms and Conditions

Non-Discrimination 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.

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.

Civil Rights Complaints

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online here, 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 using one of the following methods:
• Mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
• Fax: (202) 690-7442
• Email: program.intake@usda.gov

This institution is an equal opportunity provider.

By clicking accept, I affirm that I have been advised of my rights and obligations under the Senior Farmers Market Nutrition Program. I certify that the information I have provided for my eligibility determination is correct, to the best of my knowledge. This form is being submitted to receive 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 fines from the State Agency and may subject me to criminal prosecution under State and Federal law.

I am 60 years of age or older, or 55 and Native American; my household income falls within federal income poverty guidelines; I have not applied for Senior Farmers Market Nutrition Program coupons or checks at any other location; and I will follow all Senior Farmers Market Nutrition Program guidelines.

I acknowledge the above statements and accept all of the above terms and conditions.

Summary

Senior Farmers Market Nutrition Program Form

Are you eligible to use the SFMNP program?

Assessment Information

Select all that apply:

Terms and Conditions

Non-Discrimination Statement

Civil Rights Complaints