Form HRP-1052A "Commodity Senior Food Program (Csfp) Notice of Action" - Arizona

What Is Form HRP-1052A?

This is a legal form that was released by the Arizona Department of Economic Security - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2021;
  • The latest edition provided by the Arizona Department of Economic Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HRP-1052A by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

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Download Form HRP-1052A "Commodity Senior Food Program (Csfp) Notice of Action" - Arizona

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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1052A FORFF (1-21)
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
NOTICE OF ACTION
Client Name:
CSFP ID:
Date of Notice:
CSFP Distribution Agency Information
Name:
Phone Number:
Address:
Distribution Days and Hours:
Additional Details:
Details
The Commodity Senior Food Program (CSFP) works to improve the health of low-income persons 60 years of age or
older by supplementing their diets with nutritious foods provided by the United States Department of Agriculture (USDA).
The monthly food package contains shelf-stable items and a large block of processed American cheese.
We are writing to inform you of the following:
You have been placed on a waiting list to receive CSFP benefits because the current
Waiting List
caseload for this site is full. A representative will contact you once there is an opening.
Application Denial
Date of Denial:
. Your application has been denied for the following reason(s):
Disqualification
You will be disqualified from receiving CSFP as of:
for the following reason(s):
Discontinuance
Our records indicate you have not picked up a CSFP box since
.
Please pick-up your CSFP box by
to avoid being discontinued. Contact the
agency listed above if you have questions.
Rights and Responsibilities
Discontinuance: If you don’t pick up your CSFP box for 2 months in a row, you will be discontinued from the program
and your box will be given to a person on the waiting list. If you have trouble picking up your box, please speak with the
distribution agency listed above.
Dual-Participation: You may not receive a CSFP box twice in the same month. Improper use or receipt of CSFP
benefits, as a result of dual-participation, or other program violations may lead to a claim against you to recover the value
of the food and may lead to disqualifying you from CSFP.
Nutrition Education: You have the right to receive nutrition education, including referrals to other programs and
agencies that may benefit you.
Fair Hearing: If you disagree with any of the above action(s), you have the right to request a fair hearing. To request a fair
hearing, call 480-521-5700, or write the Food and Nutrition Division. You may continue to receive benefits pending the
outcome of the fair hearing. However, if the fair hearings official decision is not in your favor, you will be held liable for any
over issuances received while awaiting the outcome of the fair hearing. You have 90 days from the date of this notice to
request a fair hearing.
See reverse for USDA/EOE/ADA disclosures
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1052A FORFF (1-21)
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
NOTICE OF ACTION
Client Name:
CSFP ID:
Date of Notice:
CSFP Distribution Agency Information
Name:
Phone Number:
Address:
Distribution Days and Hours:
Additional Details:
Details
The Commodity Senior Food Program (CSFP) works to improve the health of low-income persons 60 years of age or
older by supplementing their diets with nutritious foods provided by the United States Department of Agriculture (USDA).
The monthly food package contains shelf-stable items and a large block of processed American cheese.
We are writing to inform you of the following:
You have been placed on a waiting list to receive CSFP benefits because the current
Waiting List
caseload for this site is full. A representative will contact you once there is an opening.
Application Denial
Date of Denial:
. Your application has been denied for the following reason(s):
Disqualification
You will be disqualified from receiving CSFP as of:
for the following reason(s):
Discontinuance
Our records indicate you have not picked up a CSFP box since
.
Please pick-up your CSFP box by
to avoid being discontinued. Contact the
agency listed above if you have questions.
Rights and Responsibilities
Discontinuance: If you don’t pick up your CSFP box for 2 months in a row, you will be discontinued from the program
and your box will be given to a person on the waiting list. If you have trouble picking up your box, please speak with the
distribution agency listed above.
Dual-Participation: You may not receive a CSFP box twice in the same month. Improper use or receipt of CSFP
benefits, as a result of dual-participation, or other program violations may lead to a claim against you to recover the value
of the food and may lead to disqualifying you from CSFP.
Nutrition Education: You have the right to receive nutrition education, including referrals to other programs and
agencies that may benefit you.
Fair Hearing: If you disagree with any of the above action(s), you have the right to request a fair hearing. To request a fair
hearing, call 480-521-5700, or write the Food and Nutrition Division. You may continue to receive benefits pending the
outcome of the fair hearing. However, if the fair hearings official decision is not in your favor, you will be held liable for any
over issuances received while awaiting the outcome of the fair hearing. You have 90 days from the date of this notice to
request a fair hearing.
See reverse for USDA/EOE/ADA disclosures
HRP-1052A FORFF (1-21) – Reverse
Nondiscrimination Disclosure
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: http://www.ascr.usda.gov/complaint_filing_cust.html, 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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