Administration and Forms for FMNP

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Administration and Forms for FMNP

FMNP Forms

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Form Name	Form Number	Program Name
Annual Audit	AUDIT	FMNP Forms
Application for Texas Identification Number	AP-152	FMNP Forms
Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion for Covered Contracts	H2048	FMNP Forms
Certification Regarding Federal Lobbying	H2049	FMNP Forms
Claim for Reimbursement		FMNP Forms
Direct Deposit Authorization	74-176	FMNP Forms
Disclosure of Lobbying Activities		FMNP Forms
Disclosure of Lobbying Activities Continuation Sheet		FMNP Forms
F&N Complaint Form - English		FMNP Forms
F&N Complaint Form - Spanish		FMNP Forms
Farmers' Market Nutrition Program Allowed-Disallowed Foods	H1442	FMNP Forms
Farmers' Market Review		FMNP Forms
Farmers' Voucher Redemption List		FMNP Forms
FMNP Agreement Between Contracting Entity and Famers’ Market Association	FMNP-02	FMNP Forms
FMNP Agreement Between TDA and Contracting Entity	FMNP-01	FMNP Forms
FMNP Agreement Between TDA and Contracting Entity – AMENDMENT	FMNP-01A	FMNP Forms
FMNP Farmer Profile and Agreement Between Farmer and Farmers’ Market Association	FMNP-03	FMNP Forms
Food Calendar	H1443	FMNP Forms
Participant Voucher Issuance Log		FMNP Forms
Payee Change Request	74-157	FMNP Forms
Plan of Operation	H1406	FMNP Forms
S/FMNP Locations and Site Information	H1420	FMNP Forms
Vendor Integrity Evaluation Report		FMNP Forms

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Assistance available in English and Spanish. Please call 877-TEX-MEAL (877-839-6325) for help. Additional translations services available as well.

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 and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made 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-0508-0002-508-11-28-17Fax2Mail.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; or

2. Fax: (833) 256-1665 or (202) 690-7442; or

3. Email: program.intake@usda.gov.

This institution is an equal opportunity provider.