Form Hrp-1042a Forpdf - Commodity Senior Food Program (Csfp) Waiting List Notification
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1CSFP
Commodity
Senior Food
Program
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1042A FORPDF (8-17)
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
WAITING LIST NOTIFICATION
APPLICANT INFORMATION
APPLICANT NAME
DATE OF BIRTH
NOTICE DATE
ADDRESS (No., Street)
CITY
STATE
ZIP CODE
PHONE NUMBER
ALTERNATIVE CONTACT NAME
PHONE NUMBER
Home Phone
Work Phone
Message Phone
Pager
I do not have a Telephone
TELEPHONE NUMBER IS FOR A:
COMMENTS:
It has been determined that you may meet the criteria to participate in the Arizona Commodity Senior Food Program
(CSFP). However, at this time, caseload slots or funding are not available to provide services to all the applicants who may
qualify. You are being placed on a waiting list and will be notified when it is possible for you to reapply for program benefits.
Since Federal regulations limit the number of individuals served by CSFP to the annual assigned caseload and does not
provide for over serving this caseload, an applicant’s placement on a waiting list due to lack of available caseload is not
considered a denial of service and therefore is not subject to appeal.
Health and/or public assistance referral made?
Yes
No
CLIENT/AUTHORIZED REPRESENTATIVE SIGNATURE
DATE
DISTRIBUTION SITE STAFF SIGNATURE
DATE
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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