Work Information

Employer Name

Enter the name of the farm owner or place of agricultural/meatpacking employment

Employer State/Territory

Profession

Relief payments are not available to farm owners or farm operators through the FFWR Program, except for those with proof of employment as farmworkers or meatpackers on farms they do not also own or operate.

Type of work performed (and associated SOC/NAICS Code)

Please list some of the agricultural products you worked with

Examples: chicken, mushrooms, carrots, etc.

What work do you do at this job?

Please describe at least two activities that your performed regularly at this job

Did you work in this role between January 27, 2020 and May 11, 2023?

YesNo

Personal Information

First Name

Last Name(s)

Middle Name(s)

Suffix

Date of birth MM-DD-YYYY

MONTH-DAY-YEAR

Address Information

I do not have address information

Street Address

City

State/Territory

Zip Code (5 digit)

Identification Document Upload

Identification Documentation

Identification Documentation Upload

Additional Identification Documentation (optional)

Additional Identification Documentation Upload

Employment Document Upload

Employment Documentation must prove employment between January 27, 2020 and May 11, 2023 to be eligible for the program

Employment Documentation for this profession

Employment Documentation for this profession upload

Additional Employment Documentation for this profession (optional)

Additional Employment Documentation for this profession upload

H2A/H2B visa Validation

You may only use H2A/H2B visa as either Proof of Identity OR Employment Documentation, but not both.

Payment Information

How would you like to receive your payment?

Check (Mailed to you)ACH (Direct Deposit to Bank Account)

Mailing Address

My mailing address is the same as my address information (entered above)

Street Address

City

State/Territory

Zip Code

ACH Bank Information

Routing number on left bottom of check with account number to the right of it

Bank Account Type

CheckingSavings

Person's Name on Bank Account

Enter the name of the person who controls this bank account

Routing Number

Routing Numbers are always 9 digits (include leading 0's)

Account Number

Confirm Account Number

Account Number and Confirm Account Number do not match.

Intake Method

How did you learn about this program?

If "Other referral" please describe or select a partner organization below

Were you referred by a partner organization?

Applicant's Declaration

I am filing this form on behalf of:

Myself as the beneficiaryAnother individual who is the beneficiary

Information of person filing this form

Name

Reason for filing on behalf of another individual

Relationship to applicant

Organization

Phone

Email address

Street

City

State

Zip Code

I certify that I incurred expenses preparing for, preventing exposure to, and/or responding to the COVID-19 pandemic such as, but not limited to: costs for personal protective equipment (PPE), expenses associated with quarantines and testing, and dependent care.

I certify that I am eligible to receive a Farm and Food Workers Relief (FFWR) payment based on the program eligibility criteria.

I certify that I have not received a Farm and Food Workers Relief (FFWR) payment previously through another entity.