Application For Food Stamps (Page 4 of 4) in pdf

Application For Food Stamps Page 4

FSP 901 (Rev. 8/04)

(Page 4) (English)

I understand that I can be prosecuted



if I provide false information.



if I hide information.

Interview and re-interview information



I understand the budget reflects the expenses I tell you about.

Expenses not disclosed will not be budgeted in calculating the amount of my food stamps.

I understand that I must cooperate with the State Quality Control Reviewer.

Signature of Applicant/Recipient

Date:

In accordance with Federal law and U. S. Department of Agriculture and U.S. Department of Health and Human Services

policy, this institution is prohibited from discriminating on the basis of



race.



color.



national origin.



sex.



age.



religion.



political beliefs.



disability.

To file a complaint of discrimination, write

USDA Director

HHS Director

Office of Civil Rights

Room 326-W

Room 506-F

Whitten Building

200 Independence Avenue

1400 Independence Avenue SW

Washington, D.C. 20201

Washington, DC 20250-9410

Call (202)619-0403 (voice)

Call (202) 720-5954 (voice and TDD)

Call (202)619-3257 (TDD)

USDA and HHS are an equal opportunity provider and employer.

S:workingwfnjformFSP-901 (English).doc

Application For Food Stamps Page 4

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