Upon completion of this form, you hereby withdraw from the Mariposa Food Co-op.

Departing Owner Name *
Departing Owner Name
Phone *
Forwarding Address *
Forwarding Address
Departure Date *
Departure Date
After this date, you will no longer receive your owner benefits. Note, it may take up to 2 weeks from your departure date before you receive your refund check.
The Mariposa Owner Fund is a pool of funds dedicated to increasing food access to low-income owners by subsidizing part of Co-op Ownership. Find more information at www.mariposa.coop/owner-fund
We value your feedback. Please share the reason/s you're leaving the Co-op. *