Assistance Application

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If you, or someone you know, has experienced some form of devastation and is in need of assistance from Ag Community Relief, please fill out this form

Are you filling out the application for yourself or for someone else? *

Myself

Someone Else

If you are filling out the application for someone else, please list your name, phone and email here. In the application list the information for the person who has experienced devastation.

First Name *

Last Name *

Phone *

Email *

City *

State *

Zip *

Describe your operation and the devastation that you have encountered. Please list as much detail as possible. *

Submit

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