Please read or have the following information read to you.

Scope of Program
AZFMNP offers qualified seniors the opportunity to purchase fresh, locally grown fruits and vegetables at participating farmers’ markets in Arizona. Applicants approved for coupons will receive AZFMNP coupons and a printed participant guide with an explanation of how to use the coupons.

AZ Farmers Market Nutrition Program – Summary of Rights and Responsibilities
The following is a non-comprehensive summary. Refer to the Participant Guide for full details.
As a program participant, you have the right to:
• Receive a Participant Explanation Guide
• Fair treatment from all market staff, approved growers, and program administrators
• You may file a civil rights discrimination complaint with the USDA
• File a dispute and a fair hearing if you are determined ineligible for AZFMNP coupons
• Receive program information in the language of your choosing
As a program participant, you are responsible for following program rules:
• Provide accurate and truthful information regarding your eligibility
• Receive benefits only once per year and from only one state
• Only spend coupons on Arizona-grown produce with approved vendors
• Never attempt to sell or exchange AZFMNP coupons for cash
• Understand and abide by program deadlines
• Keep your coupons safe – they cannot be replaced if lost or stolen


Participant Acknowledgement of Rights and Responsibilities Signature

I agree to abide by the rules of the Arizona Farmers’ Market Nutrition Program. I have been advised of my rights and obligations under AZFMNP. I certify that the information I have provided for my eligibility determination is correct, to the best of my knowledge. This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the state agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under state and federal law. It is illegal to receive AZFMNP benefits from more than one state agency at a time.
Standards for eligibility and participation in AZFMNP are the same for everyone, regardless of race, color, national origin, age, disability, or sex.
I understand that I may appeal any decision made by the local agency regarding my eligibility for the AZFMNP.