Safe at the Winter Farmers’ Market Cost Share Program Application

Use this form to apply for the Safe at the Winter Farmers’ Market Cost-Share. If you have questions, contact Emily.Mehr@state.mn.us.

First name

Last name

Phone

Mailing address

City/Town

State

ZIP/Postal Code

Market association

Market website

Market location

Market county

Number of food vendors

Eligibility criteria

The farmers’ market must meet the minimum eligibility criteria in order to be reimbursed for the base amount ($200). If your market is authorized in one or more of the following programs, you may be reimbursed an additional $50 for each program selected (up to $100 in additional funding). Select all that apply to your market:

SNAP authorized for the 2020 season

Market Bucks for the Winter Farmers' Market

Equipment

Tell us what type(s) of equipment you purchased for reimbursement. Please include the store(s) where items were purchased, the quantity of items purchased, and the total cost of the purchase.

Example: 2 folding tables from Store A, $100.00 total.

Proof of purchase

Upload proof(s) of purchase (receipts, itemized paid invoices, or invoices with proof of payment such as a canceled check, bank statement, or credit card statement).

If there is sensitive information on the documents, cover or remove it before making .jpg, .png, or .pdf copies of your documents. We do not need to know your bank account or credit card information.

Upload requirements

Upload farmers’ market SNAP authorization form

If your market previously applied for the Safe at the Farmers’ Market Cost-Share Program, you do not need to resubmit this form.

Upload requirements

Provide your W-9 (required)

If you don’t have an electronic version of your W-9, go to this PowerForm Signer Information page, enter your name and email address, and click “Begin Signing” to go the W-9 in DocuSign.

Upload requirements

I acknowledge that I have read and agreed to the Privacy notice and attest that the information I am submitting is true, complete, and accurate.

Privacy notice

The information provided as a part of the Safe at the Winter Farmers’ Market Cost Share Program application will be used to access the applicant’s eligibility to receive payment under the Agricultural Growth, Research, and Innovation Program, and to fulfill applicable financial reporting requirements. Completing this application is voluntary; applicants are not legally required to provide the MDA with the information requested, but only completed applications will be considered. While much of the information applicants provide is classified by Minnesota law as public, some of the information may be classified by law as private or nonpublic at the MDA. Data classified as private or nonpublic will be accessible only to MDA employees and contractors that have a work assignment that requires access to the data, and to other entities authorized by law to receive the data. The MDA may be obligated to provide the data to law enforcement, the Minnesota Department of Administration, Minnesota Management and Budget, the Office of the State Auditor, or the Office of the Legislative Auditor. Finally, private data about you may be released to third parties through your informed consent, or pursuant to a valid court order. Internal Revenue Service code Section 6109 requires applicants to provide their correct taxpayer identification number to payers who must file information returns with the IRS. The MDA will use the information provided on the applicant’s W-9 form in order to report payments received as part of the GFAP Program to the IRS. The IRS uses the numbers for identification purposes and to help verify the accuracy of the applicant’s tax return. For more information on how the information provided on a W-9 may be used, refer to the Privacy Act Notice on page 6 of the W-9 form.