Mansfield Farms to Family

Mansfield Farms to Family

Fresh produce and CSA program
Have you previously participated in the Farms to Family Program?*

YesNo
I certify my household still resides at the same address in Mansfield, CT

YesI have moved, but still live in Mansfield, CT
We are happy to see your interested in returning to the program and want to let you know about the changes for this year.

Changes -
- Households can only sign up for either a partially sponsored CSA or the monthly distribution. If you choose the CSA option, the monthly distribuiton will not be available. This is due to the increase in households signing up for the program.
Please note the following documentation is needed to complete your application:
- Three (3) most recent pay stubs or copy of other sources of income (if applicable) i.e.: Social Security, Private Pension, Unemployment, Workman's Comp, Disability Benefits, Veterans Benefits, Rental Income, Welfare, Alimony, Child Support, etc. for all income earners in the household.
Welcome -

Please note the following documentation is needed to complete your application if you have never applied for the program:

Proof of residence - such as a copy of lease, utility bill, or mortgage statement.

Income verification - copies of three most recent paystubs or copy of other sources of income (if applicable) i.e.: Social Security, Private Pension, Unemployment, Workman's Comp., Disablity Benefits, Veterans Benefits, Rental Income, Welfare, Alimony, Child Support, etc. from all income earners in the household.

Households can only sign up for either a partially sponsored CSA or the monthly distribution. If you choose the CSA option, the monthly distribuiton will not be available. This is due to the increase in households signing up for the program.
Applicant Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Co-Applicant Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email address
example@example.com
Applicants Employers

Employers Name

Street Address

CityState / Province

Postal / Zip Code
Annual Wages*
Length of Employment
Co-Applicants Employers

Employers Name

Street Address

CityState / Province

Postal / Zip Code
Annual Wages
Length of Employment
Other Sources of Income

Other people living in the unit

	Relationship to Applicant	Date of Birth	Employer	Yearly Income
Name of Household member
Name of Household member
Name of Household member
Name of Household member
Name of Household member
Name of Household member
Name of Household member
Name of Household member
Name of Household member

Please answer the following questions so we can demonstrate to our funding source how important this program is to our community and help assess the needs.
Do you have access to transportation?*

YesNo
Do you visit a Farmer's Market to purchase local produce?*

YesNo
If so, approximately how many times a year? *
What motivated you to apply for this program? What do you hope to gain from this program? Please check all that apply.*

Access to local produceAbility to connect with local farmsHelp supplement food costOther
Have you ever participated in a Community Supported Agriculture (CSA) share?

YesNo
My household would like to participate in a partially sponsor CSA. Please note the CSA program is a cost share program and participants are responsible for a small cost to participate.

YesNo
My household would like to participate in the monthly fresh food distribution?

YesNo
How long have you lived in Storrs/Mansfield?
How many people live in your household*
Number of people over the age of 18?*
Number of children under the age of 18?*
How would you describe your race/ethnicity?*

AsianAmerican Indian/Alaska NativeBlack, African AmericanWhite, Non-HispanicMulti-racial/ethnicHawaiian/Pacific IslanderOther
What is the annual income for your household?*

Under $9,999$10,000 - $24,999$25,000 - $39,999$40,000 - $54,999more than $55,000
Do you, or anyone in your household, currently use ...?

WIC (Women, Infant, Children)Food PantryFarmers market vouchersFood Stamps (SNAP)Other sources of free or discounted food? (church, etc.)
Where do you most commonly purchase your food? (Please check all that apply)*

Convenience store/gas stationDiscount Store (Family Dollar, Dollar General, etc.)Grocery Store (Wal-mart, Big Y, Aldi, etc.)Farmers market or Roadside stand or other local producerEat at restaurants most often/go to drive-through
Do you purchase food directly from local producers?*

YesNo
If yes, which ones
If no, why not and would you be interested?
Do you find it challenging stretching your food budget to the end of the month?*

YesNo
If yes, what do you do in those months?*
Do you feel you are getting enough fruits and vegetables, eggs, milk, whole grains?*

NoYes
If no, what are the biggest reason?

Do not purchaseCost
What produce items would you like to receive on a regular basis?*
Should be Empty: