2023 Senior Farmers Market Nutrition Program

Application for $80 Senior Farmers Market benefit cards

The Senior Farmers Market Nutrition Program (SFMNP) provides fresh fruit and vegetables to lower-income seniors with the goal of improving their health and nutritional status.

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* 1. Please enter your name, mailing address, and phone number

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Phone Number *

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* 2. Which county to you live in?

Lewis County

Mason County

Thurston County

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* 3. Birth date

Month/date/year

Date

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* 4. Was this form filled out on behalf of the person listed above? If so, please provide name and organization of person filling out the form.

First and last name

Organization

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* 5. To be eligible for the SFMNP, you must:

1) Be a Washington resident
2) Be 60 years old or older (or 55+ if you are Native American/Alaska Native) and
3) your income must be below 185% of the Federal Poverty Level.

That means:

$26,973 Annual or $2,248 Monthly Income for 1 person

$36,482 Annual or $3,040 Monthly Income for 2 people

For larger households, add $792 for each additional person

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* 6. By signing this form, the person named on this application certifies that they meet all the eligibility requirements listed above and acknowledge that they have read the SFMNP Rights and Responsibilities information.

In addition, they agree that by typing their name in signature box below, they are providing the legal equivalent of a manual signature.

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* 7. Are you interested in receiving additional food? If so, we will share your information with a local food bank.

I agree to sharing my information with the local Food Bank for additional food resources.

I DO NOT consent to sharing my information with the local Food Bank for additional food resources.

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* 8. Optional Survey

How did you hear about SFMNP?

If you have received vouchers in the past, at which farmers markets did you use them?

Have you experienced any problems using the vouchers?

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* 9. Have you experienced a reduction or loss of SNAP benefits?

Yes

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* 10. Do you consider yourself Hispanic/Latino?

Please see Nondiscrimination statement on our website.

Yes

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* 11. Please check all that apply:

White

Black or African American

Asian

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

2023 Senior Farmers Market Nutrition Program

Application for $80 Senior Farmers Market benefit cards

Question Title

* 1. Please enter your name, mailing address, and phone number

Question Title

* 2. Which county to you live in?

Question Title

* 3. Birth date

Question Title

* 4. Was this form filled out on behalf of the person listed above? If so, please provide name and organization of person filling out the form.

Question Title

* 5. To be eligible for the SFMNP, you must:1) Be a Washington resident2) Be 60 years old or older (or 55+ if you are Native American/Alaska Native) and 3) your income must be below 185% of the Federal Poverty Level.That means:

Question Title

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* 7. Are you interested in receiving additional food? If so, we will share your information with a local food bank.

Question Title

* 8. Optional Survey

Question Title

* 9. Have you experienced a reduction or loss of SNAP benefits?

Question Title

* 10. Do you consider yourself Hispanic/Latino? Please see Nondiscrimination statement on our website.

Question Title

* 11. Please check all that apply:

* 5. To be eligible for the SFMNP, you must:

1) Be a Washington resident
2) Be 60 years old or older (or 55+ if you are Native American/Alaska Native) and
3) your income must be below 185% of the Federal Poverty Level.

That means:

* 10. Do you consider yourself Hispanic/Latino?

Please see Nondiscrimination statement on our website.