Missoula Food Bank 219 S. Third St. West Missoula, MT Phone (406)

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1 Missoula Food Bank 219 S. Third St. West Missoula, MT Phone (406) Dear Potential ROOTS Recipient: Thank you f your interest in receiving food from Missoula Food Bank through our ROOTS-Seni Delivery Program. Missoula Food Bank and the Department of Health and Human Services partner to deliver a free, nutritious monthly food package to senis. Each package we deliver contains juice, cereal oatmeal, boxed and dry milk, peanut butter dry beans, rice pasta, chili stew, cheese, canned fruits and vegetables and a supplement of Ensure and fresh fruit vegetables. Inventy options are limited but will try to accommodate special dietary needs you may have. To qualify f this program, you must: 1. Be 60 years of age older 2. Meet income guidelines outlined on the next page. The income infmation you supply is completely SELF-DECLARED: accdingly, we will not investigate your income personal infmation. Please complete both sides of the application fm, make your food choices, and return the application to Missoula Food Bank. If you have any questions about the application itself, program eligibility the services in general, please do not hesitate to call Jessy at (406) ext Finally, if you find you are either not eligible not interested in being a client, please help us to pass on this infmation to others who may qualify and wish to benefit from the program. We are also always looking f VOLUNTEERS! Sincerely, Missoula Food Bank Staff This project is funded (in part) under a contract with the Montana Department of Public Health and Human Services. The statements herein do not necessarily reflect the opinion of the department.

2 2015 Elderly Income Guidelines

3 ELDERLY CSFP APPLICATION ROOTS Name of Applicant Address (Number) (Street) (City) (Zip) (County) Phone No. in Household Emergency Contact: Does your household receive SNAP benefits? (fmerly known as food stamps) Y N I am able to pick up this food at the Missoula Food Bank. I need my food delivered each month to the address listed above. Qualifying Household Members: Age: Date of Birth: Categy: (leave blank) RACE: Black White American Indian/Alaskan Native Hispanic Asian/Pacific Islander HOUSEHOLD INCOME: Indicate source and amount How often of current (last month s) Amount received income befe deductions, Social Security such as taxes and Social Security. THIS AMOUNT Public Assist. (Welfare) MUST INCLUDE ALL INCOME OF ALL HOUSE- Pension/Retirement HOLD MEMBERS. If last month s income is not Self-employment representative, please project a yearly income which would Other (Specify) be. Other income could be commissions, strike benefits, income from trusts, contributions from relatives, etc. Food Stamp benefits do not count as income. TOTAL HOUSEHOLD INCOME In accdance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, col, national igin, sex, age, disability. Please see reverse side of this fm.

4 To file a complaint of discrimination, write USDA, Direct, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, D.C call (202) (voice and TDD). USDA is an equal opptunity provider and employer. I understand it is illegal to participate in the CSFP in me than one local agency, to participate simultaneously in the CSFP and in the WIC Program. This Certification Fm is being completed in connection with the receipt of Federal Assistance. Program officials may verify infmation on this fm. I am aware that deliberate misrepresentation may subject me to prosecution under applicable State and Federal Statutes. I have been advised of my rights and obligations under the Program. I certify that the infmation I have provided f my eligibility determination is crect to the best of my knowledge. (SIGNATURE OF APPLICANT) (DATE) I HEREBY AUTHORIZE THE FOLLOWING INDIVIDUALS TO ACT AS MY AUTHORIZED REPRESENTATIVE FOR CSFP: NAME RELATIONSHIP TO APPLICANT NAME RELATIONSHIP TO APPLICANT Office Use Only below this line NEW CERTIFICATION ELIGIBLE NOT ELIGIBLE CERTIFICATION DATE FROM TO TITLE OF CERTIFIER SIGNATURE DATE 2 ND CERTIFICATION ELIGIBLE NOT ELIGIBLE CERTIFICATION DATE FROM TO TITLE OF CERTIFIER SIGNATURE DATE CLIENT CONTACT BY PHONE IN PERSON CLIENT WISHES TO REMAIN ON CSFP FOR A CONSECUTIVE SIX MONTHS? CLIENT ADDRESS CHANGED? IF YES, NEW ADDRESS IF INELEGIBLE PLEASE STATE REASON: You may appeal any decision made by the local agency regarding your denial termination from the program. You have a right to a fair hearing. If your application is approved, the local agency will make nutrition education available to you and you are encouraged to participate.

5 FOOD CHOICES (subject to availability). 1. CHOOSE ONE: packages) 2. CHOOSE ONE: 3. CHOOSE ONE: 4. CHOOSE ONE: Everyone will receive: 2 bottles of Juice, 2 lbs of Cheese, Liquid Milk, Dry Milk (every other month), 2 cans of Fruit, and 4 cans of vegetables! Note: This is a federal program and we are required to deliver all of your food. If you receive an item you do not care f, cannot use, please pass on to a friend, neighb, give back to your driver at your next delivery. Thank you.