2017 Senior Farmers’ Market Coupon Reimbursement Form
Senior Farmers Market Nutrition Program ends October 31, 2017.
ALL coupons must be turned in for reimbursement by November 30, 2017.
Please complete and attach all coupons with the request form along with a self-addressed stamped envelope for
Farmer Name/Number: ________________________________________ Market Date: ___________________
Mailing Address: __________________________________ City: _________________ Zip: ____________
Phone Number: ______________________________________________________________________________
Number of coupons enclosed: ________________ x $5.00 each = Amount Requested: $__________________
Signature: ______________________________________________________ Date: _____________________
Checks will be issued on the 1
and the 15
of each month. Please submit coupons within 15 days of receipt.
Please do not wait until the end of the season for coupon reimbursement.
United Way of Mat-Su
550 S. Alaska Street, Suite 205
Palmer, AK 99645
United Way of Mat-Su Use:
Verified by: ___________________________________________
Senior Farmers’ Market Project Representative
Check Number _____________________