FSA Technical Assistance Intake Form
Page 1
Case Origin
Case Priority
Case Record Type ID
Contact Information
First Name
Last Name
Email Address
Phone Number
Street Address
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code
Are you actively farming?
Yes
Previously but not currently
No
I am an aspiring farmer
How did you hear about RAFI-USA?
Internet Search
Rafi-USA Website
Partner Organization
Social Media
Conference
Another Farmer/Word of Mouth
Other
Demographic Information
This demographic information is used for data and evaluation purposes only. It is not required to fill out but it does help us improve our services and connect you with demographic-specific opportunities.
Race
Black/African American
Latinx
Native American
Asian
Multiracial/Biracial
White
Other
Other
:
Gender
Female
Male
Non-Binary
Other
Other
:
Age Range
18-25
26-33
34-41
42-49
50-57
58-65
66-73
74-81
82-89
90-97
Preferred Language
English
Spanish
Other
Other:
Immigrant/Refugee/ESL
Yes
No
Are you a veteran?
Yes
No
Page 2
Farm Information
Tell us a little bit about your farm/ farming goals and what you are seeking assistance with.
What type of assistance are you looking for? (i.e. Farm Loan Application Assistance, Land Acquisition) Please explain
Do you have farm management experience?
Yes, I have management experience for at least 3 of the past 10 years
No, but I have other/non-farm management experience for at least 3 of the past 10 years
No, I do not have management experience
Farm Name
If your farm doesn't have a name, please enter [Your Name] Farm
Type of Farm: Check all that apply
Agritourism
Aquaculture
Aquaponics/Hydroponics
Bees
Cattle
Commodities
Poultry - Contract
Poultry - Independent
Conventional
Eggs
Fiber
Fish / Seafood
Flowers
Forestry
Fruit
Goats
Hemp
Herbs
Hogs
Horticulture
Large-Scale
Mid-Scale
Nuts
Orchard
Organic
Sheep
Small-Scale
Value Added
Vegetable
Vermiculture
Other
Other:
Total Acres in Production
Acres Owned
Acres Leased
Does your farm have a Farm ID?
Yes
No
Do you currently or previously have a working relationship with your local FSA office? Please describe
Contact Information