PARTNER SHARES PROGRAM APPLICATION
FairShare CSA Coalition | 303 S. Paterson St. #1B, Madison, WI 53703
(608) 226-0300 | [email protected] | www.csacoalition.org
First Name
Last Name
Street Address
Primary Phone Number
City
State
Best way to contact you Email  Phone
Email
How did you hear about Partner Shares?  Friend
Zip Code
 CSA Farm
Is this your first time becoming a CSA member?  Yes  No
 Newspaper  Internet
 Event  Other - Please list:
If no, which years were you a CSA member?  2009  2010  2011  2012  2013  Other ______
1. PARTICIPANT AGREEMENT:
As a Partner Shares participant, I certify with my initials and signature that:
My annual household income is at or below 185% Federal Poverty guidelines. (See Table below)
I agree to pay FairShare CSA Coalition the CSA share co-payment amount determined by my income level.
I will inform the Coalition immediately if I am having trouble making a payment, changing banking accounts or Quest card numbers, or must cancel my
farm membership.
I understand that I am making a commitment to a farm, and will be responsible for picking up my vegetable share every week throughout the season.
Yes
No, thank you: I grant FairShare CSA Coalition the permission to publish photographs of me and my family at CSA Coalition events for media and
promotional purposes.
Signature
Date
2. FARM CHOICE:
Please include a completed farm sign-up form (obtain form from chosen farm) with this application.
Household
Size
Monthly
Annual
1
$1,723
$20,676
2
2,333
$27,996
3
2,944
$35,328
4
3,554
$42,648
5
4,165
$49,980
6
4,775
$57,300
7
5,386
$64,632
8
5,996
$71,952
For each additional
family member:
+611
+7,332
CSA Farm Name
CSA Share Type*
Total Share Cost
(Ex: Full, Half, Standard, EOW)
_____________
* Only on-farm produced shares are eligible for Partner Share Program funding.
3. INCOME VERIFICATION (based on Federal Poverty Level - FPL):
In order to serve as many households as possible, FairShare utilizes an income-based fee scale.
Based on your income, FairShare will pay a portion of your CSA share payment, up to a maximum of
$300. In addition, FairShare will work with applicants who are eligible for CSA rebates from their
HMO providers to assist you in receiving your rebate.
How many members are in your household?
What is your annual or monthly household income?
per month / year (circle one)
Household Income
(185% of FPL)
FairShare CSA Coalition | 303 S. Paterson St. #1B, Madison, WI 53703
(608) 226-0300 |[email protected] | www.csacoalition.org
PARTNER SHARES PROGRAM APPLICATION
4. HEALTH INSURANCE REBATE:
a) Are you enrolled with any of these health care organizations? (Check all that apply)
 GHC- SCW  BadgerCare Plus  Physicians Plus  Unity Health  Other ______________________________
b) If you have BadgerCare, is your plan administered by GHC-SCW (Group Health) or Unity?  Yes  No
c) If you are enrolled, do you have a family or individual plan?  Family  Individual
d) If you are eligible, are you planning to apply for your insurance provider’s CSA rebate?
 Yes
 None
 No I need more information/I don’t know
For more information, please visit http://www.csacoalition.org/about-csa/csa-insurance-rebate/ or call your health care provider.
5. PAYMENT PLAN: Please select your preferred method of payment for your CSA share. Once your application and payment has been approved,
FairShare staff will notify you of the level of assistance available to you and will send the payment plan details via mail or email.
 Single Check: Pay for your co-payment with one check. A $25 deposit is required at the time of application. A confirmation letter and final payment
amount will be mailed to you upon receipt of your application and deposit.
 Multiple Checks: Make monthly payments throughout season. A $25 deposit is due at the time of application, and the full payment must be
completed by September 15, 2014. A confirmation letter and payment plan will be mailed to you upon receipt of your application and deposit.
 Quest Card: A $25 deposit is required at the time of application. Quest card payments are processed on a monthly basis from April to September. A
confirmation letter, payment plan and blank Quest vouchers will be mailed to you upon receipt of your application and deposit.
When would you prefer that we process your Quest card?
Quest Card Account #
2nd Thursday of the month 3rd Thursday of the month
______________________________________________
6. NUTRITION EDUCATION: I would like to have a nutrition educator from the Wisconsin Nutrition
Education Program contact me with more information about their free services, including phone calls
and/or home visits:  Yes  No If yes, what county do you live in? _______________________
7. APPLICATION REQUIREMENTS
The availability of shares and funding is limited. Requests for Partner Shares assistance are granted on a
first-come, first-served basis. If you have questions, call (608) 226-0300. Please send applications to the
CSA Coalition by April 15, 2014. Check should be made out to “FairShare CSA Coalition.”
You will NOT be registered with your farm until the Coalition receives your application & deposit.
You must send in ALL the following completed forms for a full application review:
 Partner Shares Application
 CSA Farm Sign-Up Form
 $25 Deposit
Special Offer!
From Asparagus to Zucchini Cookbook
This cookbook is fantastic for learning how to
best use the vegetables from your CSA share.
Partner Shares participants can purchase one
cookbook per family for a discounted price of $5!
 Yes, I would like to order this book and
have enclosed an additional $5 (cash or check)
with my completed forms.
Send completed forms and deposit to: Partner Shares Program, c/o FairShare CSA Coalition, 303 S. Paterson St. #1B, Madison, WI 53703