9 AL Exhibit 2. AL Application

USDA Nondiscrimination Statement
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, religious creed, disability, age, political beliefs, 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: http://www.usda.gov/oascr/how-to-file-a-programdiscrimination-complaint, 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; or
(3) email: [email protected].
This institution is an equal opportunity provider.

Penalty Warnings, Perjury Statement and Signature

When your household receives food assistance benefits, you must follow all the rules. You must provide true and complete information
about everyone in your household and you must provide documents to prove what you say if you are asked to by the worker. Any
member of your household who breaks any of these rules on purpose can be barred from SNAP for 1 year for first offense, 2 years for
second offense, and permanently for third offense; fined up to $250,000, imprisoned up to 20 years or both; and subject to prosecution
under other federal laws. She/he may also be barred from the Food Assistance Program for an additional 18 months if court ordered.
DO NOT give false information, or hide information to get or continue to get SNAP benefits. DO NOT trade or sell EBT cards. DO
NOT alter EBT cards to get SNAP benefits you are not entitled to receive. DO NOT use SNAP benefits to buy ineligible items such
as alcohol and tobacco or to pay on credit accounts. DO NOT use someone else’s SNAP benefits or EBT card for your household.
Individuals determined by a court to have committed the following program violations will be subject to the following penalties:

●  If you are found to have used or received benefits in a transaction involving the sale of a controlled substance, you will be ineligible to receive
SNAP benefits for a period of two years for the first offense and permanently upon the second such offense.

●  If you are found to have used or received benefits in a transaction involving the sale of firearms, ammunition or explosives, you will be

permanently ineligible to receive SNAP benefits upon the first occasion of such violation.
●  If you have been found guilty of having trafficked benefits for an aggregate amount of $500 or more, you will be permanently ineligible to
receive SNAP benefits upon the first occasion of such violation.
●  If you have been found to have made a fraudulent statement or representation with respect to your identity or place of residence in
order to receive multiple SNAP benefits simultaneously, you will be ineligible to participate in the program for a period of 10 years.
●  If you are fleeing to avoid prosecution, custody, or confinement, after conviction for a crime or an attempt to commit a crime, which is a felony,
or are in violation of probation or parole imposed under a federal or state law, you are ineligible for food assistance.
● If you are convicted of using or receiving food assistance benefits in a transaction involving the sale of a controlled substance, you will be
ineligible 24 months for the first violation and permanently for the second violation.
● If you are convicted of a federal or state felony that has an element the possession, use, or distribution of a controlled substance, you
may be ineligible for food assistance.
I certify under penalty of perjury that my answers to all questions about each household member, including those about citizenship
or alien status, are correct and complete.

Household member signature or mark (X):_____________________________________________________ Date ____________________________

Witness if signed by mark:________________________________________________________________________ Date ____________________________

DO NOT REMOVE. This page must be returned to your county office with pages 1 and 2.

To get the address or phone number of your local county office, call toll free: 1-833-822-2202 or online at www.dhr.alabama.gov
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