Form HRP-1037A FORPDF "Commodity Senior Food Program (Csfp) Notification of Expiration" - Arizona

What Is Form HRP-1037A FORPDF?

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 August 1, 2017;
  • 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;

Download a fillable version of Form HRP-1037A FORPDF 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-1037A FORPDF "Commodity Senior Food Program (Csfp) Notification of Expiration" - Arizona

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CSFP
Commodity
Senior
Food
Pro
gram
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1037A FORPDF (8-17)
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
NOTIFICATION OF EXPIRATION
APPLICANT NAME
NOTICE DATE
Your certification to participate in the Commodity Senior Food Program is EXPIRING.
The effective date of disqualification is:
If you wish to continue receiving benefits after the program expiration date, contact your Distribution Site before the
program end date to recertify your eligibility for CSFP.
DISTRIBUTION SITE NAME:
DISTRIBUTION SITE PHONE NUMBER:
DISTRIBUTION SITE ADDRESS:
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.
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: 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.
CSFP
Commodity
Senior
Food
Pro
gram
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1037A FORPDF (8-17)
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
NOTIFICATION OF EXPIRATION
APPLICANT NAME
NOTICE DATE
Your certification to participate in the Commodity Senior Food Program is EXPIRING.
The effective date of disqualification is:
If you wish to continue receiving benefits after the program expiration date, contact your Distribution Site before the
program end date to recertify your eligibility for CSFP.
DISTRIBUTION SITE NAME:
DISTRIBUTION SITE PHONE NUMBER:
DISTRIBUTION SITE ADDRESS:
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.
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: 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.