Form Hrp-1036a - Commodity Senior Food Program (Csfp) Notification Of Disqualification
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1
2CSFP
Commodity
Senior
Food
Pro
gram
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1036A FORPDF (8-17)
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
NOTIFICATION OF DISQUALIFICATION
APPLICANT NAME
NOTICE DATE
You have been DISQUALIFIED from participating in the Commodity Senior Food Program (CSFP) for the following
reason:
Intentionally making false or misleading statements, orally or in writing
Intentionally withholding information pertaining to CSFP Eligibility
Selling commodities obtained in the program or exchanging them for non-food items
Physical abuse, or threat of physical abuse, of program staff
Other:
The effective date of disqualification is:
Program standards are applied without discrimination based on 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.
Health and/or public assistance referral made?
Yes
No
PROGRAM STAFF SIGNATURE
DATE
If you do not agree with this decision and wish to appeal, your appeal request may be submitted verbally or in writing.
Requests for an informal dispute resolution meeting must be submitted within twenty (20) calendar days from the Notice
Date at the top of this form. Requests for a fair hearing must be submitted within sixty (60) calendar days from the Notice
Date at the top of this form.
An informal dispute resolution meeting is an informal meeting between you, the distribution site director, involved
distribution site staff and a representative from the Department of Economic Security (DES), who will preside over the
meeting. If you request an informal dispute resolution meeting, DES will notify you of the time, date and meeting procedure
at least fifteen (15) calendar days before the meeting.
If you do not wish to request an informal dispute resolution meeting, you may request a fair hearing. You may also request
a fair hearing to appeal the decision made in an informal dispute resolution meeting. A fair hearing is an administrative
hearing before an impartial DES official. A decision is made within forty-five (45) days from the date the fair hearing request
was received. The fair hearing request must contain a statement of facts, the reasons you believe you are entitled to a fair
hearing and the relief sought.
At a fair hearing, you have the right to self-representation or to be represented by a relative, friend, legal counsel or other
spokesperson. You also have the right to bring witnesses, introduce arguments, question or refute testimony or evidence,
confront and cross-examine adverse witnesses and submit evidence to support your case.
See reverse for USDA nondiscrimination and EOE/ADA/LEP/GINA statements
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