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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 aware that 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, including the right to appeal any decision made by the local agency regarding my denial or termination from the Program. I understand that the local agency will make nutrition education available to me and I am encouraged to participate. 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.)

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity, gender expression, and sexual orientation), disability, age, marital status, family/parental status, income derived from public assistance programs, political beliefs, or reprisal or retaliation for prior credible activity, in any program or activity conducted or funded by USDA (not all bases ally to all programs) or any civil rights activity. Remedies and complaint filing deadlines vary by program or incident. Program information may be available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information(e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-25-17Fax2Mail.pdf, from any USDA office, by calling(866)632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant's name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted 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: (833) 256-1665 or (202) 690-7441; or (3) email: program.intake@usda.gov.

Dare to Care Food Bank, the Kentucky Department of Agriculture, and the Indiana Department of Health does not discriminate on the basis of race, color, religion, gender, national origin, age (over 40), sexual orientation, gender identity, disability, genetics, ancestry or veteran status. Reasonable accommodations are provided upon request.

The Kentucky Department of Agriculture does not discriminate on the basis of race, color, religion, gender, national origin, age (over 40), sexual orientation, gender identity, disability, genetics, ancestry or veteran status. Reasonable accommodations are provided upon request.