STATE OF WISCONSIN
DEPARTMENT OF HEALTH SERVICES
Division of Health Care Access and Accountability
F-01696 (02/2016) /

APPLICATION FOR FARMERS’ MARKET SNAP EQUIPMENT FUNDING

Name of Farmers’ Market Authorized Representative / Farmers’ Market Name
Telephone (including area code) / Email Address
MailingAddress / City, State, Zip Code
1.Location of Farmers’ Market (street number and name or intersection, city, state, zipcode)
2.Length of time this Farmers’ Market has been in operation
3.Area served by Farmers’ Market (zip code or other geographic information such as neighborhood and city names)
4.Number of food vendors/booths at the location
5.Dates and hours of operation (e.g. May 1 – October 31, Wednesdays 7:00 am – 1:00 pm)
6.What types of food products are offered at this Farmers’ Market (e.g. vegetables, fruit, cheese, meat, honey)
7.Does this Farmers’ Market currently operate under an individual authorization from USDA FNS to accept SNAP benefits?
YesDate of Authorization:Name of Authorized Agency:
No
8.If no, has this Farmers’ Market started the SNAP authorization process with FNS?
Note: Farmers’ Markets that have not started the authorization process with FNS by March 4, 2016, will not be eligible to receive this funding.
Yes
No
9.Since each selected farmers’ market is eligible for only one (1) wireless POS device, farmers’ markets must develop a process toallow customers to purchase food from multiple vendors using one POS device. What process does this Farmers’ Market plan to use?
Please see for examples. Attach an additional sheet of paper if necessary.
10.It is understood that this funding will only be used to provide one (1) wireless POS device for each selected Farmers’ Market and that the State Agency will provide funding for the flat monthly wireless service fees through September 30, 2016.
Yes
11.It is understood that the responsibilities listed in this application are not inclusive, and that the Farmers’ Market will enter into an agreement with the State Agency that will include all responsibilities for the SNAP equipment received through this funding.
Yes

I have agreed to submit this document by electronic means. By signing this application electronically, I understand that this is an application for funds to purchase a POS device for accepting SNAP benefits. Submission of this application does not guarantee this Farmers’ Market will be awarded funding. I am authorized to enter into this agreement on behalf of the Farmers’ Market. I understand that an electronic signature has the same legal effect and can be enforced the same way as a written signature.

By checking this box and typing my name below, I am electronically signing my application.

SIGNATURE—Farmers’ Market Authorized Representative / Date Signed

Please submit application no later than February 26, 2016 ications will only be accepted by email. Questions may be directed to: Katie Vieira at r (608)-261-7832.