[Code of Federal Regulations]
[Title 7, Volume 4]
[Revised as of January 1, 2007]
From the U.S. Government Printing Office via GPO Access
[CITE: 7CFR247.8]

[Page 411-412]
 
                          TITLE 7--AGRICULTURE
 
    CHAPTER II--FOOD AND NUTRITION SERVICE, DEPARTMENT OF AGRICULTURE
 
PART 247_COMMODITY SUPPLEMENTAL FOOD PROGRAM--Table of Contents
 
Sec.  247.8  Individuals applying to participate in CSFP.

    (a) What information must individuals applying to participate in 
CSFP provide? To apply for CSFP benefits, the applicant, or the adult 
parent or caretaker of the applicant, must provide the following 
information on the application:

[[Page 412]]

    (1) Name and address, including some form of identification for each 
applicant;
    (2) Household income, except where the applicant is determined to be 
automatically eligible under Sec.  247.9(b)(1)(i) and (b)(1)(ii);
    (3) Household size, except where the applicant is determined to be 
automatically eligible under Sec.  247.9(b)(1)(i) and (b)(1)(ii); and
    (4) Other information related to eligibility, such as age or 
pregnancy, as applicable.
    (b) What else is required on the application form? The application 
form must include a nondiscrimination statement that informs the 
applicant that program standards are applied without discrimination by 
race, color, national origin, age, sex, or disability. After informing 
the applicant (or adult parent or caretaker) of his or her rights and 
responsibilities, in accordance with Sec.  247.12, the local agency must 
ensure that the applicant, or the adult parent or caretaker of the 
applicant, signs the application form beneath the following pre-printed 
statement. The statement must be read by, or to, the applicant (or adult 
parent or caretaker) before signing.
    ``This application is being completed in connection with the receipt 
of Federal assistance. Program officials may verify information on this 
form. I am aware that deliberate misrepresentation may subject me to 
prosecution under applicable State and Federal statutes. I am also aware 
that I may not receive both CSFP and WIC benefits simultaneously, and I 
may not receive CSFP benefits at more than one CSFP site at the same 
time. Furthermore, I am aware that the information provided may be 
shared with other organizations to detect and prevent dual 
participation. I have been advised of my rights and obligations under 
the program. I certify that the information I have provided for my 
eligibility determination is correct to the best of my knowledge.
    I authorize the release of information provided on this application 
form to other organizations administering assistance programs for use in 
determining my eligibility for participation in other public assistance 
programs and for program outreach purposes. (Please indicate decision by 
placing a checkmark in the appropriate box.)


YES [ ]

NO [ ]''


(Approved by the Office of Management and Budget under control number 
0584-0293)