Dairy Workers Association, Inc.

Goodwill Benefit Fund Application

Use this confidential form to request emergency financial assistance from the DWA Goodwill Benefit Fund. Submission does not guarantee approval or a particular award amount.

Please protect your privacy.

This application is sent only to the two designated DWA reviewers. Upload only what is necessary to support your request. Do not include Social Security numbers, bank or account numbers, full medical records, or unrelated personal information. Ordinary email may not provide end-to-end encryption; contact a representative before sending highly sensitive material.

Applicant information

First name

Last name

Employee identification number

Email address

Phone number

Dispatch location

Position

Assistance request

Completed years in the Union

Your service will be verified against DWA records.

Financial aid requested

Choose your completed years of service to see available amounts.

What occurred that led you to request Goodwill Benefit Fund assistance?

Supporting information

Do you have a corroborating witness or testimony that can validate the situation?

Yes No

If yes, identify the witness or describe the available testimony.

Within the last six months, have you been under any stage of progressive discipline, including a write-up or suspension?

Yes No

If yes, please explain.

Supporting document (optional)

One PDF, JPG, or PNG only; maximum 10 MB. Upload only information necessary to review this request.

Certification and signature I certify that the information in this application is true and complete to the best of my knowledge. I authorize the designated DWA reviewers to use it only to evaluate this Goodwill Benefit Fund request.

Type your full legal name as your electronic signature

Application date

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