LOUISIANA COMMODITY SUPPLEMENTAL FOOD PROGRAM PARTICIPANT CERTIFICATION
Webster
Computer ID# _________________________________ Parish: _______________________________ Pickup Site Grp. ___________________
Totty Charles G
Name: ________________________________________________________________________________________________________________
LAST FIRST MIDDLE
56056 Highway 2
Mailing Address: ________________________________________________________________________________________________________
Sarepta
City _________________________________________________________State LA 71071
_______________________Zip__________________________
Telephone ( 578 0217
) ______________________________________________ Male
Gender (sex) ___________________________________________
1300
Total Monthly Income $_________________ SS Fixed
Inc. Type________ 1
_Y ___N Household #____________ 07301961
Date of Birth_________________
Ethnicity (choose yes or no)
Hispanic/Latino Yes No x
Race (you may choose more than one)
American Indian or Alaska Native Native Hawaiian or other Pacific Islander
Asian White or Caucasian x
Black or African American
Alternates ___________________________________ __________________________________________
Certifying Clerk __________________________________________________ Participant ID Type___________________________________
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 [ ]
I certify that I have received my food package less refusals.
_______________________________________________________________________________________________________________________________
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: ttp://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;
(3) email:[email protected].
This institution is an equal opportunity provider.
Revised 04/2019
