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Company

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Application Information

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Application year(Required)

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Language and Type

Applicant details

Proof of Current WIC Participation(Required)

Please upload screenshot of WIC shopper’s App or EzWIC app Family Balance screen to confirm active WIC status. Sample:

WIC Sample

Max. file size: 98 MB.

Please indicate your WIC provider

Guardian Name(Required)

First Last

Phone(Required)

Ok to leave voicemail at this number?

Yes

Email(Required)

Coupons for approved applicants will be mailed to the address above by default. Check this box if you would like to OPT OUT of mailing. A program representative will contact you for alternatives to mailing if your application is approved.

Mailing Address

Arizona residents only

Street Address Address Line 2 City State ZIP Code

County of residence(Required)

Preferred Language:(Required)

English

Español

Other

Household Information

In 2026, the AZFMNP is offering 1 $50 coupon booklet per household. At the same time, it benefits the program to understand how many individuals are receiving WIC benefits within your household to assess the full demand for the farmers market program, and to identify and advocate for additional funding. For this reason, the application includes questions about individual participants even though the FMNP benefit will be distributed at $50 in coupons per household in 2026.

How many WIC recipients are currently in your household?(Required)

(WIC recipients include: infants at least 6 months old, children 1-5 years, and pregnant, postpartum, or breastfeeding women/adults)

Participating WIC Client First Name *(Required)

Participating WIC Client Last Name *(Required)

Participating WIC Client Date of Birth *(Required)

Client Category:(Required)

Add another active WIC family member

(WIC recipients include: infants at least 6 months old, children 1-5 years, and pregnant, postpartum, or breastfeeding women/adults)

Yes

Second Participating WIC Client First Name *(Required)

Second Participating WIC Client Last Name *(Required)

Second Participating WIC Client Date of Birth *(Required)

Second Client Category:(Required)

Add a third active WIC family member

(WIC recipients include: infants at least 6 months old, children 1-5 years, and pregnant, postpartum, or breastfeeding women/adults)

Yes

Third Participating WIC Client First Name *(Required)

Third Participating WIC Client Last Name *(Required)

Third Participating WIC Client Date of Birth(Required)

Third Client Category:(Required)

Add a fourth active WIC family member

(WIC recipients include: infants at least 6 months old, children 1-5 years, and pregnant, postpartum, or breastfeeding women/adults)

Yes

Fourth Participating WIC Client First Name *(Required)

Fourth Participating WIC Client Last Name *(Required)

Fourth Participating WIC Client Date of Birth(Required)

Fourth Client Category:(Required)

Add a fifth active WIC family member

(WIC recipients include: infants at least 6 months old, children 1-5 years, and pregnant, postpartum, or breastfeeding women/adults)

Yes

Fifth Participating WIC Client First Name *(Required)

Fifth Participating WIC Client Last Name *(Required)

Fifth Participating WIC Client Date of Birth(Required)

Fifth Client Category:(Required)

Participant Rights and Responsibilities Acknowledgement and Signature(Required)

Scope of Program

AZFMNP offers qualified WIC household the opportunity to purchase fresh, locally grown fruits and vegetables at participating farmers’ markets in Arizona. Applicants approved for coupons will receive AZFMNP coupons and a participant guide with an explanation of how to use the coupons.
AZ Farmers Market Nutrition Program – Summary of Rights and Responsibilities
The following is a non-comprehensive summary. Refer to the Participant Guide for full details.
As a program participant, you have the right to:
• Receive a Participant Explanation Guide
• Fair treatment from all market staff, approved growers, and program administrators
• You may file a civil rights discrimination complaint with the USDA
• File a dispute and a fair hearing if you are determined ineligible for AZFMNP coupons
• Receive program information in the language of your choosing
As a program participant, you are responsible for following program rules:
• Provide accurate and truthful information regarding your eligibility
• Receive benefits only once per year and from only one state
• Only spend coupons on Arizona-grown produce with approved vendors
• Never attempt to sell or exchange AZFMNP coupons for cash
• Understand and abide by program deadlines
• Keep your coupons safe – they cannot be replaced if lost or stolen

Participant Acknowledgement of Rights and Responsibilities Signature

I agree to abide by the rules of the Arizona Farmers’ Market Nutrition Program. I have been advised of my rights and obligations under AZFMNP. I certify that the information I have provided for my eligibility determination is correct, to the best of my knowledge. This certification form is being submitted in connection with the receipt of Federal assistance. Program officials may verify information on this form. I understand that intentionally making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts may result in paying the state agency, in cash, the value of the food benefits improperly issued to me and may subject me to civil or criminal prosecution under state and federal law. It is illegal to receive AZFMNP benefits from more than one state agency at a time.
Standards for eligibility and participation in AZFMNP are the same for everyone, regardless of race, color, national origin, age, disability, or sex.
I understand that I may appeal any decision made by the local agency regarding my eligibility for the AZFMNP.

I confirm that I have read and understood the terms outlined above.

Signature(Required)

Program use only: Collect signature offline.

USDA Non-Discrimination Statement

In accordance with federal civil rights law and USDA civil rights regulations and policies, the USDA, its agencies, offices, employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the state or local agency that administers the program or contact USDA through the Telecommunications Relay Service at 711 (voice and TTY). Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: 1. Mail: USDA Food and Nutrition Service, 1320 Braddock Place, Room 334 Alexandria, VA 22314; or 2. Email: [email protected]. USDA is an equal opportunity provider, employer, and lender.

Arizona Farmers Market Nutrition Program

Application Information

Applicant details

Household Information

Optional Questions (race & ethnicity):

USDA Non-Discrimination Statement

Arizona Farmers Market Nutrition Program

Arizona WIC Farmers Market Nutrition Program (AZFMNP) Application

Arizona WIC Farmers Market Nutrition Program (AZFMNP) Application

Application Information

Applicant details

Household Information

Optional Questions (race & ethnicity):

USDA Non-Discrimination Statement

Arizona Farmers Market Nutrition Program