Form HRP-1039A "Commodity Senior Food Program (Csfp) Participant Rights and Obligations" - Arizona

What Is Form HRP-1039A?

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, 2020;
  • 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 printable version of Form HRP-1039A by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

ADVERTISEMENT
ADVERTISEMENT

Download Form HRP-1039A "Commodity Senior Food Program (Csfp) Participant Rights and Obligations" - Arizona

Download PDF

Fill PDF online

Rate (4.6 / 5) 11 votes
Page background image
CSFP
Commodity
Senior Food
Program
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1039A FORPD (1-20)
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
PARTICIPANT RIGHTS AND OBLIGATIONS
Our Pledge to You
Your Pledge to CSFP
Supplemental Foods
Honesty
• CSFP provides you with a supplemental food box once
• CSFP food benefits you, and you may not sell or
a month.
trade the food (the intention alone may be grounds for
removal from the program).
• CSFP will make nutrition education available to all
participants, authorized representatives and proxies.
• If CSFP determines you have attempted to sell or had
the intention to sell any food benefits verbally, in print
Fair Treatment
or online, you will be subject to disqualification.
• CSFP rules are the same for everyone.
• You may enroll at only one CSFP location at a time
• You have a right to appeal a decision made by CSFP
and may not receive benefits at more than one CSFP
staff about your eligibility.
location at the same time.
Privacy
• ID/Transfer Cards are unique to you and must not be
changed or altered.
• Unless you specifically authorize otherwise, all
information you give to CSFP will be kept private.
Protect Your Benefits
Help Getting Enrolled in Other Services
• Keep your CSFP ID/Transfer Card safe.
• If you move to a different area, your CSFP information
Accurate Information
may be shared with the new CSFP agency.
• Provide current and truthful information (CSFP staff
• CSFP provides referrals to health and social services
may verify that the information is correct).
programs that may be able to help you.
Good Use of the Program
• Be courteous and respectful toward CSFP staff.
• Following the rules of CSFP is important to avoid being
disqualified from the program, prosecuted for program
violations and/or asked to repay program benefits.
• You will pick up your CSFP box monthly. If you are
going to miss a month, you will notify your CSFP site
location. If you miss picking up your box for more than
two months, you forfeit your enrollment in the program
and will be placed on a Wait List.
By signing below, I agree to all of the rights and obligations listed on this form.
Client Name
Client Signature
Date
Authorized Representative 1 Name
Authorized Representative 1 Signature
Date
Authorized Representative 2 Name
Authorized Representative 2 Signature
Date
Agency Certifier Name
Agency Certifier Signature
Date
See reverse for USDA/EOE/ADA/LEP/GINA disclosures
CSFP
Commodity
Senior Food
Program
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1039A FORPD (1-20)
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
PARTICIPANT RIGHTS AND OBLIGATIONS
Our Pledge to You
Your Pledge to CSFP
Supplemental Foods
Honesty
• CSFP provides you with a supplemental food box once
• CSFP food benefits you, and you may not sell or
a month.
trade the food (the intention alone may be grounds for
removal from the program).
• CSFP will make nutrition education available to all
participants, authorized representatives and proxies.
• If CSFP determines you have attempted to sell or had
the intention to sell any food benefits verbally, in print
Fair Treatment
or online, you will be subject to disqualification.
• CSFP rules are the same for everyone.
• You may enroll at only one CSFP location at a time
• You have a right to appeal a decision made by CSFP
and may not receive benefits at more than one CSFP
staff about your eligibility.
location at the same time.
Privacy
• ID/Transfer Cards are unique to you and must not be
changed or altered.
• Unless you specifically authorize otherwise, all
information you give to CSFP will be kept private.
Protect Your Benefits
Help Getting Enrolled in Other Services
• Keep your CSFP ID/Transfer Card safe.
• If you move to a different area, your CSFP information
Accurate Information
may be shared with the new CSFP agency.
• Provide current and truthful information (CSFP staff
• CSFP provides referrals to health and social services
may verify that the information is correct).
programs that may be able to help you.
Good Use of the Program
• Be courteous and respectful toward CSFP staff.
• Following the rules of CSFP is important to avoid being
disqualified from the program, prosecuted for program
violations and/or asked to repay program benefits.
• You will pick up your CSFP box monthly. If you are
going to miss a month, you will notify your CSFP site
location. If you miss picking up your box for more than
two months, you forfeit your enrollment in the program
and will be placed on a Wait List.
By signing below, I agree to all of the rights and obligations listed on this form.
Client Name
Client Signature
Date
Authorized Representative 1 Name
Authorized Representative 1 Signature
Date
Authorized Representative 2 Name
Authorized Representative 2 Signature
Date
Agency Certifier Name
Agency Certifier Signature
Date
See reverse for USDA/EOE/ADA/LEP/GINA disclosures
HRP-1039A FORPD (1-20) – Reverse
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.
Page of 2