Senior Farmers' Market Coupon Reimbursement Form - United Way

Senior Farmers' Market Coupon Reimbursement Form - United Way - 2017

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

check processing.

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.

Mail to:

United Way of Mat-Su

550 S. Alaska Street, Suite 205

Palmer, AK 99645

Phone: 907-745-5824

United Way of Mat-Su Use:

Verified by: ___________________________________________

Date: _________________

Senior Farmers’ Market Project Representative

Check Number _____________________

Updated 2.22.2017

Senior Farmers' Market Coupon Reimbursement Form - United Way - 2017