Farm Aid COVID-19 Farmer Resilience Initiative Grants To fill out this form, please print out the application and write-in answers OR download the document and complete the answers in Microsoft on your computer. Click ‘File’ in the upper left corner of the screen to do either of these actions. You will not be able to edit directly on this document. The grant funding is $500 and is meant to lessen the immediate financial needs of farmers and their households. This means funds could cover expenses like food, medical bills, utility bills, etc. The funds are NOT meant to cover farm- related expenses. In this round, we are able to award funding to farmers in South Carolina, Virginia**, Florida, or the US Virgin Islands. The IRS guidelines regarding direct assistance to farm families prevent us from granting funds to support the farm and its business costs. Your acceptance of this grant award signifies your understanding and agreement to these use requirements. **Note: The following counties in Virginia are NOT eligible for this grant: Alleghany, Bath, Bland, Botetourt, Buchanan, Carroll, Craig, Dickenson, Floyd, Giles, Grayson, Henry, Highland, Lee, Montgomery, Patrick, Pulaski, Rockbridge, Russell, Scott, Smyth, Tazewell, Washington, Wise, and Wythe. Contact Community Food Alliance for information about funding covering this region. (https://cfaky.org/) Application Due: June 15, 2020, 6 pm SUBMIT APPLICATION: Email a scanned copy of this application to Jarred White at jarred@rafiusa.org OR Mail your application (postmarked by June 15th) to: Farm Aid grant C/o RAFI-USA P.O. Box 640 Pittsboro, NC 27312. Priority Applicants Because available funds are limited, we will prioritize farmers who: 1) are severely impacted by COVID-19 to the degree that they are struggling to cover ordinary expenses, 2) are not able to access other federally-funded emergency relief funds (i.e. PPP, EIDL), and 3) earn a substantial portion of their household income from farming. As funds are limited, we ask that farmers carefully consider whether this emergency relief grant applies to their situation. Questions? If you have questions about the application or are having difficulty accessing the application, contact Jarred White at jarred@rafiusa.org. RESPONSES ARE REQUIRED FOR ALL QUESTIONS UNLESS LISTED AS OPTIONAL 1. First name: 2. Last name: 3. Mailing Address (Include your full mailing address - street address, town/city, and zip): Street Address - City/Town - State - Zip Code - 4. County: 5. Phone number: 6. Email address: (optional) 7. Date of birth: 8. What is your gender? 9. What is your racial or ethnic identity? 10. Farm address (if different from above): 11. Farm name/Business name: 12. Which of these describes your farm? (select all that apply) a. Contract poultry b. Independent poultry c. Dairy d. Hog e. Cattle f. Large-scale (gross cash farm income more than $1,000,000 per year) g. Mid-scale (gross cash farm income between $350,000 and $999,999 per year) h. Small-scale (gross cash farm income less than $350,000 per year) i. Organic j. Vegetable k. Commodities l. Fiber m. Hemp n. Eggs o. Bees p. Sheep q. Goats r. Valued-added products s. Fish/Seafood t. Agritourim u. Other 13. Number of acres in production? 14. Please describe your farm’s marketing channel(s). 15. Anything else we should know about your farm’s products? (optional) 16. How long have you been farming? 17. How many people does your farm employ? (please check both family & non-family as it applies) Family ❏ Myself & family Non-family ❏ 1-2 employees, non-family ❏ 3-5 employees, non-family ❏ 6-10 employees, non-family ❏ More than 10 employees, non-family 18. What percentage of your income is derived from farming? ❏ 1-5% ❏ 6-10% ❏ 11-25% ❏ 26-50% ❏ More than 50% 19. How has the COVID-19 impacted your farm business? (please be detailed) 20. By what percentage do you expect your farm income to be reduced due to the COVID-19 outbreak? ❏ 1-10% ❏ 11-20% ❏ 21-40% ❏ 41-60% ❏ 61-80% ❏ 81% or more 21. Please describe your family’s current financial situation. (please be detailed) 22. Please describe how the funds will be used. 23. Has anyone in your family or farm operation received a Farm Aid COVID-19 Farmer Resilience Initiative award? 24. Please provide contact information for a reference who can verify the farm information you have provided. Preferably, this should be a professional reference (i.e. a County Extension Agent, seed dealer, etc.) and not a personal reference. Name: __________________________________________________________ Relationship to you: ________________________________________________ Phone Number: ___________________ Email Address: ____________________________ Conditions of the RAFI-USA COVID-19 Farm Emergency Grant ❏ I understand that this application is for a grant of $500 to be used for household expenses, including medical bills, and may not be used for professional expenses related to my farm operation. ❏ I certify that no one in my family or farm operation has received an emergency grant from Farm Aid or RAFI-USA in the past 12 months. ❏ I certify that all the information in this application is complete and correct to the best of my knowledge. ❏ I agree that RAFI-USA has the right to validate any information provided and will reclaim any money that has been paid as a result of fraudulent or misleading claims. Print Name: _____________________________________________ Signature:________________________________________________ Date: ___________________