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
or
HHS Director
Office of Civil Rights
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