Department of Health and Human Services Family Independence 19 Union Street 11 State House Station Augusta, Maine 04933-0011 Tel (207) 624-4168: Fax: (207) 287-34 Pad age Gomme Mery C. Moy, Commie Toll-Free (800) 442-6001; TTY Users: Dial 711 (Maine R v) Food Supplement Program Community Services Volunteer Verification Form | To Certifying Agency: Some Food Supplement recipients must meet federal work requirements to | receive Food Supplement benefits. One way recipients can meet work requirements is to do | volunteer work (sometimes called workfare) for a nonprofit organization. The fecipient can do volunteer services at one or more, agencies for up to the value of their monthly Food Supplement benefit: We ask that you complete and sign the statement below to verify the hours the recipient | volunteered for your organization. Please return this form to: | | Farmington DHHS District Office | | 114 Corn Shop Lane Farmington, Maine 04938 Or Fax to (207) 778-8429 Or Email: Farmington. dhhs@maine.gov._ Thank you for your assistance. | / ; p / \ certifythat > y (Name), (Case 1D number) Isa volunteer for_\ L h KL (Name 8f Organization) Locanitse 1 WHY SE | incadn We. ‘Agency address) During the month of _| OVP (VKO0 1 20 |tvolunteered JM hours. (Date) Wipe Grell Vonage SIGNATURE\ TITLE AIOE LON BHOST DATE PHONE NUMBER Viena me hinaky Meoyuot EMAIL ADDRESS: MAILING ADDRESS