EmailMe Form - Hurricane Sally Relief Application

Name *

First Last

Address *

Street Address City State / Province / Region Postal / Zip Code

Name of Farm *

County *

Farm Address *

Street Address City State / Province / Region Postal / Zip Code

County *

Any Award of Funds Should Be Made Payable To: *

Mail Any Relief Funds To: *

Street Address City State / Province / Region Postal / Zip Code

Home Phone *

### - ### - ####

Mobile Phone *

### - ### - ####

Email *

Describe Farm *

100 Word Limit

Describe Farm Damages Caused by Hurricane Sally *

300 Word Limit

Describe Your Uninsurable, Non-Recoverable Loss / Expense *

300 Word Limit

What Assistance Have You Received, Or Do You Expect to Receive, From Other Agencies? *

200 Word Limit

Upload Documentation 1

Include up to four documents including receipts for repair, documentation of damage, photos, etc.

Upload Documentation 2

Include up to four documents including receipts for repair, documentation of damage, photos, etc.

Upload Documentation 3

Include up to four documents including receipts for repair, documentation of damage, photos, etc.

Upload Documentation 4

Include up to four documents including receipts for repair, documentation of damage, photos, etc.

Signature *

Clear

The undersigned authorizes the Committee to review this Application. The information contained in this Application, including the amount of relief provided, if any, will remain confidential.

I certify the information provided on and in connection with this form is true, accurate, and complete. I also understand that any false statements or deliberative omissions on this document may be grounds for disqualification from consideration.

I understand all decisions made by the Committee and the Alabama Farmers Agriculture Foundation are final.

Date Time *

MM / DD / YYYY