Form Hrp-1041a - Commodity Senior Food Program (Csfp) Waiting List Enrollment Notification
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1CSFP
Commodity
Senior
Food
Pro
gram
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1041A FORPDF (8-17)
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
WAITING LIST ENROLLMENT NOTIFICATION
APPLICANT INFORMATION
APPLICANT NAME
NOTICE DATE
ADDRESS (No., Street)
CITY
STATE
ZIP CODE
You were placed on a waiting list for the Arizona Commodity Senior Food Program (CSFP) on
.
At that time, we were not able to enroll you in the program. This letter is to inform you that it may now be possible for you
to be enrolled and begin receiving program benefits.
If you are still interested in participating in CSFP, you must contact the closest Distribution Site in your area to be screened
for eligibility.
The requirements for this program specify that you must be at least 60 years of age, present acceptable identification, verify
your address and meet Federal income guidelines. Gross household income includes, but is not limited to, the following:
• Earned income from employment or self-employment, such as salary, hourly wages, commissions or fees;
• Unemployment insurance compensation;
• Social Security Administration benefits, including Supplemental Security Income;
• Government civilian employee and military retirement, pension, or veteran’s payments;
• Private pension and retirement payments; and
• cash contributions (i.e. gift funds) received from persons not in the household
Please call
to schedule an appointment or for more information about this notice.
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. 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) 632-9992. 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. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. This institution is an equal
opportunity provider.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination
in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age,
disability, genetics and retaliation. To request this document in alternative format or for further information about this policy,
contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.
• Disponible en español en línea o en la oficina local.
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