U.S. Department Labor Employment and Training Administration

0MB Control No. 1205-0134 Expiration Date: December 31, 2018

Agricultural and Food Processing Clearance Order ETA Form 790 Orden de Empleo para Obreros/Trabajadores Agricolas y Procesamiento de Alimentos

(Print or type in each field block - To Include additional Information, go to block# 28 - Please follow Step•By·Slep Instructions) (Favor de usar letra de molde en la sollcllud - Para incluir informacl6n adlcional vea cl punto # 28 - Favor de seguir las lnstrucclones paso•a-paso)

1. Employer's and/or Agenl's Name and Address (Number. Street. City, State and Zip Code/ Nombre y Oirecci6n def Empleador/Palr6n y/o Agenle(Ntimero, Calle, Ciudad. Estado y C6digo Postal ):

Slory Farms. LLC Manc Story. Manager 4640 Route 32 Catsl<il, NY 12414

Steven McKay. Agent (3007 County Roule 20, Hudson, NY 12534 info@h2expressinc.com, 518-451-0109, 866-210-1791 rax

Federal Employer Identification Number (FEIN) / Ntimero federal de ldenbficaci6n del Empleador: 01 ·062 04 95

b)Telephone Number I Ntimero de Telelono: 518-678-9716. cell 518-610-4613

c)Fax Number/ Ntimero de Fax: none

E-ma� Address /Direcci6n de Correo Electr6nico: mdmvidsto m11il.com2. Address and Directions to Work Site / Domicilio y Direcciones at lugar detrabajo:4640 RI. 32. Catskill. NY 12414

(Owned by fixed-site farmer)

3. Address and Directions lo Housing/ Domicilio y Direcciones al lugarde vivlenda:

4640 RI. 32, Catskill NY 12414

Desaiplion of Housing I Descripci6n de la vivienda: Mobile home, 4 bedrooms living room, bathroom, kitchen/dining room, /fully furnished, all utilities provided: oi heal electric; capacity 6 (2 H2A worlters); Catskill Urgent Care, Catskill is closest medical facility; recreafion possible: jog. TV, bll<e, fish

Nos. 4 through 8 for STATE USE ONLY Numeros 4 a 8 para USO EST AT AL

4. SOC (O"NET/OES) OccupationalCode I C6digo Industrial:

lfS;i..o� JO{?

5.Job Order No. / Num. de Orden deEmpleo·

a. SOC (ONET/OES) OccupationalN\ f 1..., LL 3, J_ 'vTille I Tltulo Ocupacional l � 1 \(.,1',(:) O Agricultural Equipment

Operator6. Address of Order Holding Office (include Telephone number)/ Direcci6n de

la Oflcina donde se radico la oferta (incluya el numero de telefono):

31'7,- 'f4,(f)-q'1S1 a Name of Local Office Representative (include direct dial telephone

number)/ Nombre del Representanle de la Oficina Local (lncluya el nt'.Jmero do lelefono de su llnea direcla).

7. Clearance Order Issue Dale I Fecha de Emisi6n de la Orden de Empleo:

o/7/U)fg 8. Job Order Expiration Date I Fecha de Vencimiento o Explraci6n de la Orden

de Empleo:g l � ;l/ ;)O I r

9. Anticipated Period of Employment / Periodo anticipado o previsto de Empleo:

From/ Desde: 05/15/2018 To I Hasta· 11/30/2018

10. Number of Workers Requested / Nt'.Jmero de Trabajadores Solicilados: 2

11. Anticipated Hours of Work per Week I Horas Anliclpadas/Previstas deTrabajo por Semana. Total: 40

Sunday / Domingo___ Thursday /Jueves_.:..7 __Monday I Lunas 7 Friday I V18mes 7Tuesday I Martes -!7__ Saturday I S�bado 5Wednesday I Miercoles,_,!..7 __

12. Anticipated range of hours lot different seasonal activities:/ Rangoprevislo de horas par alas drferentes actlvidados de la temporada:

Plant crops 40 hrSM'k Water, fertilize, prune plants: 40 hrs Harvest fruits and vegetables: 40 hours per wook Maintenance: 20 hours r week

13. Collect Calls Accepted from:/ Aceptan Uamadas por Cobrar de:

Employer/ Empleador:

By

Yes/SiO NoXXO

MARO 5 20\8

14. Describe how the employer intends to provide either 3 meals a day to each worker or furnish rree and convenient cooking and kitchen facilltles for workers to preparemeals / Describa c6mo el empleadOf tiene la intenci6n de ofrecer. ya sea 3 cormdas al dia a cada trabajadOf, o proporcionar graluitamente instalaciones para cocinar

Transportation provided weekly to purchase food and supplies; beneficiaries will buy and prepare their 0\\/Jl food in fully furnished kitchen.

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15. Referral tnstruciions and Hiring Information / lnstrucciones sobre c6mo Referir Candidatos/Solicitantes. (Explain how applicants are to be hired 0< referred, and theEmployer's/Agent's available hour lo interview workers I Explique c6mo los candidatos seran contratados o referidos, y las horas disponibles def empleador/agente para entrevistar a los trabajadores). See instructions for more details / Vea las instrucciones para mas detalles.

Inquire at: 4640 Rt. 32, Catskill. NY 12414. or call 518-678-9716 for interview with Mark Story. �Available 8 am to 12 noon for calls.

Or apply through nearest NYS DOL One Stop Career Center. Please contact (877) 466-9757 to locate nearest State Workforce Agency office.

16. Job description and requirements/ Descripci6n y requisitos de! trabajo: Manually plam, cultivate, and hanrcst vegetables, fruits, and field crops. Usehnnd tools to till, fertilize, transplant, weed. thin, prune, stake, t:n:llis, apply pesticides, clean, irrigate, and load produce. Operate, repair, maintaintractors/implements to grow and harvest crops. Mix and apply agrichemicals, mnimain fences and buildings. Lift up to 70 pounds. 6 m onths verifiableexperience. (Crops: broccoli. cauliOowcr. cabbage, com. st rawberries, summer squash. peppers. onions. tomatoes. potatoes, winter squash, blueberries,raspberries, eggplant, hay)

Equipment list: small tractors, lawn mowers, small farm implements, haying equipment

Sembrar. cultivar, y cosechar manualmcnto vcgetales, frutas, y pucas de pasto. Utilisa herramicntas do mano para harar, abonar, tnmsplantar, deshierbar, podar, aplicar pesticidas. limpiar, regar agua. y cargar producto. Operar, repar.i.r. y mantener tractorcs/implerm:ntos para cultiv11r y cosechar cultivos. Mesclar y apticar egroquimicos, mantener cdi ficios y cercas. Levan tar hasI11 70 libras. Require 6 meses de expcricncia en lo mcncionado.

Is previous work experience required? I Se require previa experiencia? Yes / Si XXO No a If yes, number of months required:/ Si es asi. numero de meses de experiencia: _6 __

Requirements thal apply: D XX Exposure to Extreme Temp./ Expuesto a Temperaturas Extremas a XX Frequent St ooping/ lnclinandose o agachandose con frecuencla DXX Lifting requirement/ Levantar o Cargar _70_1bs./libras a XX Repelilive Movements/ Movlmlentos repeUtivos, Extensive sitting. walking. pushing/pulling

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17. Waoe Rates, Special Pav Information and Deductions I Tarifa de PaQo, lnformaci6n Sabre Pagos Especiales y Deducciones (Rebaiasl

Crop Activities Hourly Wage Piece Rate I Special Pay Deductions' Yes!Si No Pay Period / '

diverse fruit and Unit(s) (bonus, etc.) Per!odo de ·Pago I veaetable mix hav

I

Cultivos Salario por Hora Pagos Especiales Dcducciones I I

Pago par Pieza / (Bono, etc.)

Unidad(esl Plant $12.83 n/a nla Social Security I xxO 0 Weekly I Semanal

Seciuro Social Irrigate $12.83 n/a n/a Federal Tax/ xxD 0 xxO

lmpuestos Federales ;

Remove weeds, $12.83 n/a nla State Tax xxO 0 Bi-weekly/ prune /lmpueslos Quincenal

Estatales Harvest S12.83 n/a nfa Meals I Comidas 0 xxO 0

Maintenance S12.83 n/a n/a Other (specify) / 0 xxO Monthly/Mensual Olro (especlfica)

t

V'¥: !me C4 l,., o.u tdlvw«, (.N:,b� 1

C<, r"'1 Other/Otro !

�!Pt,rt'I(( S,(Un,mtr��UCfi'h1 f�I (J)i1mf htYl�

��J,Wlnii:-"6'<A9J\, b �fl , r,.rpbHfiu 1d tth,-l�t. 0

18. More Details About the Pay / Mas Detalles Sobre el Pago:

Federal tax option: Foreign H2A worker may choose to have federal taxes deducted

Opcion de las lmpuestos federales: Trabajador extranjero H2A puede eliglr si quiere deduccion de impuesto federal.

19. Transportation Arrangements I Arreglos de Transportaci6n

Employer agrees to reimburse inbound transportation and subsistence expenses ($12.07 per day for a maximum of $51.00 as specified by regulations) to each worker and any person, government agency, or private organization which on behalf of the worker has paid or advanced such transportation and subsistence expenses from the residence, place of last employmenl, or place of recruitment to the job site after the worker has completed 50% of the stipulated period of employment, from initial date of need or from the day after actual arrival of worker if later than the stated date to report. Return expenses also paid.

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20. Is it the prevailing practice to use Farm Labor Contractors (FLC) to recruit, supervise, transporl, house, and/or pay workers for this (these) cropactivity (ies)? / lEs la practica habitual usar Contraiistas de Trabajo Agricola para reclutar, supervisar, transportar, dar vivienda. y/o pagarle a los trabajadores para este{os) tlpo(s) de cosecha(s)? Yes I Si O No xxO

Ir you have checked yes. what is the FLC wage for each activity? I SI contesto 'Si.' cual es el safario que le paga al Contratista de Trabajo Agrfcofa por cada actividad?

21. Are workers covered for Unemployment Insurance?/ lSe le proporcionan Seguro de Desempleo a los trabajadores? Yes/S19( No xtil-

22 Are workers covered by workers' compensation?/ lSe le provee seguro de compensaci6n/indemnizaci6n al trabajador: Yes/Si xD No 0

23. Are tools, supplies. and equipment provided at no charge to the workers?/ lSe fes proveen herramienlas y equipos sin costo alguno a lostrabajadores?

Yes/Si xO No a

24. Lisi any arrangements which have been made with establishment owners or agents for the payment of a commission or other benefits for sales made to workers. (If there are no such arrangements, enter 'None'.) I Enumere todos tos acuerdos o convenlos hechos con los propielarios delestablecimiento o sus agenles para el pago de una comisi6n u otros beneficios por ventas hechas a tos trabajadores. (Si no hay ning(m acuerdo o convenio, indique 'Ninguno'.) None

25. List any stn1<e, work stoppage, slowdown, or interrupiion of operafioo by the empk)yees at the place where the workers wm be employed. (If there are no such incidents, enter 'None'.) I Enumere toda huelga. paro o interrupci6n de operaciones de trabajo por parte de los empleados en el lugar de empleo. (Si no hay incidenles de este tipo, indique 'Nlnguno'.) None

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27. Employer's Certification: This job order dewibes the c,ctual terms end conditions or the employment being offered by me end contains all the materiel terms and conditions of the Job./ Certlficacl6n de! Empleador: Esta orden de ttabajo describe los terminos y condiciones det empleo que se le olrece, y contiene todos los t�rmlnos y condlciones materiales ofrecidos.

Mark Story, Manager �"" 7 & TI,, I

::.:

• oo '"' do M•d,11•••"' d•I Emplo,d,,

I I/ c.'l,f � 0212s1201s

Employer's Signature IF� lo dilipleador Date I Fecha

READ CAREFULLY, In view of tho slalulorily established basic !unction of the Employment Service as a no-fee labor exchange, that Is, as a forum for bringing together employers 11nd job seekers, neither the Employment and Training Administration (ETA) nor the Stale agencies are g1Jara111ors of the accuracy or truthfulness of information contained on job orders submitted by employers. Nor does any job order accepted or recruited upon by the American Job Center constitute a contractual job offer to which the American Job Center, ETA or a State agency is in any way a party.

LEA CON CUIOADO, En vi5fa de la won baslc.1 del Ser.icio de Empleo �da por ley, ccmo una entidad de Wercamlio laboral si1 amsiones. es dedr, como un faro pa,a reunr a bs empeadores y bs sollcitan1es de empleo, ri ET A ni las agendas del estado p.ieden garanti?ar la mlCfilJd o verac.idad de le informad6n oonh!nida en las 6rdenes de trabajo some!idas por los errpeadores. Ni ninguna orden de b'abajo acep(ado o contratado en el Centro de carreras (American Job Ceolef) consfluyen ooa der1a de lrllbajo ainlr.lduales a las que el American Job Center, ET A o un organlsmo estatal es de IWljluna manera una de las partes.

PllBUC BURDEN STATEMENT The public repo,1ing burden for respond.rig lo ETA Fonn 790, v.tlich Is required to obtain or retail benefits(.« USC 3501), is emiated lo be approximately 60 mnAMP.« respor,$8, inclucing time fQt r8Wl'Mng lnsll\Jdlons, seardwlg ela$1ing data $0U101!$, galhering and re-.iev,(ng the c:oledion. The public need nol reapond lo this ccledio,i cl information uriessit displays a cunenUy valid 0MB Corrtrol Number. This Is pubic lnlorma6on and lhere is no �tion d conlidentiaity. SeM comments reganing llis bunleo estinate or erry oflef aspect d Ns c:oledion, inwdilg suggestions ror redudng llis tuden, to the U.S. Depas1ment ol l.abor, � and Tranng Adninistrellon. Office ofWcnforce lrwestmen1, Room C-4510, 200 � Avenue, tffl. Wasmgtoo. DC 20210.

DECURAC10N DE CARGA PUBUCA La carga de informaci6n p(dca para responder a la Forma ET A 790, que se requlere para obteoer o retener beneliclos (44 USC 3501), se "1ima en apro� 60 minutos por respuMta, intilj80do el tiempo para reviser las insltoccio!les, buscar !uentes de da!os exlstentes, recop1ar y re'lisar la cciea::i6n. El publico no lione por qu6 responder a esta recopilaci6n de lnformaci6n a menos que rooeslre un numero da control 0MB valido. Esta inf0fTl18ci6n es pt)hlica y no hay ningooa e)l)edafiva de cootidendalidad. Envle sus cornentaioli a= de es1a carva o cualquler otto aspedo de esta coleccioo, induyendo sugerenda$ para reducir esta cwga, al U.S. Department ct Labor, Employment and Training Ad/ninislralion, Office ofWoridorte lnY8Stment, Room C-4510. 200 Conslilution Avenue, NW. Washington, DC 20210.

28. Use this stdon lo prot,ide additional $Uppo'1ing lnforma6on (lndodlng section Box number). lndude allachments, if necessary. I Utillce asla '8Cdon para proporcionar informacion addonal de apoyo; incluya el nurne,o de la secci6n e incluya archi\10$ adjoolos, sf es ne<:esario.

None

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28. Use this section to provide addaional supponing information (including section Box number). Include allachments, if necessary. I Ulilice esta secci6n para proporcionar informaci6n adicional de apoyo; incluya el numero de la secci6n e inciuya arcnlvJS adjuntos, si es necesario.None

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the specified hourly rate or pay, or In the absence of a specified hourly rate or pay, the higher of the Federal or State minimum wage rate for the first week starting with the original anticipated date of need. The employer may require workers to perfonn alternative work If the guarantee is Invoked and if such alternative work is stated on the job order.

The employer agrees that no extension of employment beyond the period of employment shown on the job order will relieve the employer from paying the wages already earned, or specified in the job order as a term of employment, providing transportation or paying transportation expenses to the worker's home.

The employer assures that all working conditions comply with applicable Federal and State minimum wage, child labor, social security, health and safety, farm labor contractor registration and other employment-related laws.

The employer agree.s to expeditiously notify the OHO or State agency by telephone Immediately upon learning that a crop Is maturing earlier or later, or that weather conditions, over recruitment, or other factors have changed the terms and conditions of employment.

The employer, If acting as a farm labor contractor, has a valid farm labor contractor registration certificate.

The employer assures the availability of no cost or public housing which meets applicable Federal and State standards and which is sufficient to house the specified number of workers requested through the clearance system.

The employer also assures that outreach workers shall have reasonable access to the workers in the conduct of outreach activities pursuant to 20 CFR 653.107.

Employees Name: Mmt. �•gt �;:: Employer's Signature L.t.Latf t,, �

02/15/2018

Besides the material terms and conditions of the employment, the employer must agree to these assur11nces If the Job order is to be placed aa part of the Agricultural Recruitment System. This assurance statement must be signed by the employer, and It must accompany the ETA Form 790.

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Form ETA 790 Attachment State of: NY Terms and Conditions/Clarifications and Assurances/ Additional Information

A: CLARIFICATION OF ITEMS ON FORM ET A 790 Item 3: Housing a. Housing and utilities are provided at no cost to H-2A workers and those workers incorresponding employment who are unable to return to their place of residence thesame day.b. Housing beds, bedding, and mattresses will be furnished at no cost to the workers.c. Housing will be clean and meet the applicable Federal and State housing standards.d. Workers will be responsible for maintaining housing and surrounding areas in a neat,clean manner.

Item 14: Board Arrangements Employer will not provide three meals per day. Employer will furnish free dishes, cooking utensils and convenient kitchen and cooking facilities. Employer will provide transportation to assure workers access to stores where they can purchase groceries and/or other incidentals, and/or medical necessities.

Item 16: Job Specifications a. Workers must be able to demonstrate that they are physically able to perform thework as described.b. The employer will provide NIA days of training and/or allow NIA days of work forworker to reach production standards if applicable.c. Employer may terminate worker with timely notification to the NPC and OHS, if theworker:1) Refuses, without cause, to perform work for which the worker was recruited and hired;2) Commits serious acts of misconduct; or3) Abandons Job (" Job Abandonment") - is absent for five consecutive previouslyscheduled days without prior notification to employer.

Item 17 Wage Rates, Special Pay Information and Deductions

The employer will offer, advertise in its recruitment, and pay a wage that is the highest of the AEWR, the prevailing hourly wage or piece rate, the agreed upon collective bargaining wage, or the Federal or State minimum wage, except where a special procedure is approved for an occupation or specific class of agricultural employment. Employer assures that if a change in the AEWR requires an increase such increase will be paid as of the effective date of the increase. Also if the AEWR is decreased this will become the wage effective on the date of the decrease. a If piece rate earnings for total hours of work at a piece rate during a pay period do not result in average hourly earnings equal to the guaranteed minimum hourly rate, the worker will receive make-up pay to the guaranteed minimum wage rate.

b. In New York State, the only deductions that can be taken from worker pay are:1. Those required by law, such as Social Security, income tax, and garnishment of

wages;and

2. Those that benefit workers and are authorized in writing, such as life insurance,or a savings account. Any other deductions are illegal. c. The employer guarantees to offer employment for a minimum of . ("three-fourthsguaranteen) of the hours in the workdays during the period of the contract, and allextensions thereof. This guarantee begins with the first workday after the worker's arrivalat the place of employment and ends on the date specified on the job order orextensions thereof. In fire, weather, or Act of God terminations (as determined by theCertifying Officer) the . guarantee period ends on the date of termination. The employermust make efforts to transfer the worker to other comparable employment acceptable tothe worker. consistent with existing immigration law. as applicable. If such a transfer isnot affected, the employer must (1) return the worker. at the employer's expense, to theplace from which the worker (disregarding intervening employment) came to work for theemployer, or transport the worker to the worker's next certified H-2A employer,whichever the worker prefers; (2) reimburse the worker the full amount of any deductionsmade from the worker's pay by the employer for transportation and subsistenceexpenses to the place of employment; and (3) pay the worker for any costs incurred bythe worker for transportation and daily subsistence to that employer's place ofemployment. Daily subsistence must be computed as set forth in paragraph (h) of655.122. The amount of the transportation payment must not be less (and is not requiredto be more) than the most economical and reasonable common carrier transportationcharges for the distances involved provide the guarantees in Item 19 (a) below.

d. Workers will not be required to work more than the number of hours specified in thejob order for a workday or on their Sabbath or federal holidays to meet this guarantee.The worker's average hourly earnings will be used under this guarantee where wagesare paid on a piece rate basis. Workers who are terminated for cause or who voluntarilyabandon their job are not entitled to this guarantee if employer provides timelynotification to the NPC and OHS.e. On or before each payday the employer will provide to each worker in one or morewritten statements the following information: (1) the worker's total earnings for the payperiod; (2) the worker's hourly rate and/or piece rate of pay; (3) the hours of employmentoffered to the worker (showing offers in accordance with the . guarantee as determinedin paragraph (i) of the regulations at 20 CFR sec. 655.122(k), separate from any hoursoffered over and above the guarantee); (4) the hours actually worked by the worker; (5)an itemization of all deductions made from the worker's wages; (6) if piece rates areused, the units produced daily; (7) beginning and ending dates of the pay period; and (8)the employer's name, address, and FEIN.f. Workers with school age children who have migrated with such children and whodepart in time to return home for the beginning of the school year shall be paid, inaddition to the basic wages, any bonus or other incentive payments or other expenses towhich they would be entitled had they stayed the entire job order period.g. The employer will provide workers referred through the interstate clearance system 40hours of work for the week beginning with the anticipated date of need, unless employerhas amended the date of need by notifying the SWA no later than 10 business daysbefore the date of need. If the employer fails to notify the NYS DOL, then the employershall pay an eligible worker referred through the clearance system$ 513.20 (number ofhours of work x AEWR/prevailing wage/minimum wage) for the first week starting withthe originally anticipated date of need. If worker referred fails to notify the NYS DOL ofcontinued interest in the job at least 5 days before date of need, worker will bedisqualified from this assurance. Employer will not require worker to perform alternativework if the guarantee cited in this section is invoked.h. Employer will maintain adequate payroll records. Workers will be paid weekly on

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Wednesday for work through the previous Monday.

Item 19: Transportation

Employer agrees to reimburse inbound transportation and subsistence expenses ($12.07 per day minimum to a maximum of $51.00 per day) to each worker, or any person, government agency, or private organization which, on behalf of the worker, has paid or advanced such transportation and subsistence expenses, from the place from which the worker has come to work for the employer, whether in the U.S. or abroad to the place of employment, after the worker has completed 50% of the stipulated period of employment, from initial date of need or from the day after actual arrival of worker if later than the stated date to report. In determining the appropriate amount of reimbursement for meals for less than a full day, the employer may provide for meal expense reimbursement, with receipts. up to 75 percent of the maximum reimbursement for meals, or $38.25. a. Employer will provide or pay the cost of return transportation and subsistence to eachworker who completes the employment period, or who is terminated for medical reasons,or as the result of fire, weather, or an Act of God (as determined by the CertifyingOfficer), from place of employment to place of recruitment, except if the worker prefersnot to return to his place of recruitment and has subsequent employment with anemployer - see Item 17 ( c) above. Employer will not be responsible for providing returncost of transportation and subsistence from place of employment to place of recruitmentif the worker voluntarily abandons the job or is terminated for cause and employerprovides timely notification to the NPC and OHS.

b. The amount of the transportation payment will be equal to the most economical andreasonable similar common carrier transportation charges for the distance involved. Alltransportation provided by the employer will be by common carrier or othertransportation facilities which conform to the applicable regulations of the InterstateCommerce Commission or the United States Department of Labor. The amount of dailysubsistence will be in accordance with current rates published in the Federal Register(for workers with and without receipts).c. If requested by the worker, employer will assist in making transportationarrangements.d. Employer will provide transportation, at no cost to the worker, from the employerprovided housing to the actual work site and return at the end of the day.

Item 22: Workers' Compensation

The employer assures that Policy# Z-305 120-8 issued by NYSIF provides the required insurance for injuries or disease arising out of and in the course of employment. Employer's proof of insurance coverage will be provided to the Chicago Processing Center before certification is granted.

Item 23: Tools and Equipment The employer will furnish without cost all tools, supplies, or equipment required in the performance of work.

B: OTHER CLARIFICATIONS ANO ASSURANCES

1. The employer agrees to abide by the regulations at 20 CFR 653.501 and 20 CFR655.135.2. The employer will expeditiously notify the State agency by telephone immediatelyupon learning that a crop is maturing earlier or later, or that weather conditions, over-

recruitment, or other factors have changed the terms and conditions of employment. 3. Outreach workers shall have reasonable access to the worker in the conduct ofoutreach activities pursuant to 20 CFR 653.501 (xvi).4. If applicable, the employer is certified In the use and application of pesticides perFederal Environmental Protection Agency and State Department of EnvironmentalConservation requirements. The employer assures that workers hired under this orderwho will be handling pesticides will be provided appropriatetraining, if applicable.5. The employer will provide to an H-2A worker no later than the time at which thewori<er applies for the visa, or to a worker in corresponding employment no later than onthe day work commences, a copy of the work contract between the employer and theworkers in a language understood by the worker.6. The employer assures that if acting as a farm labor contractor (FLC) or farm laborcontractor employee (FLCE) on the order, he/she has a valid federal FLC certificate orFLCE identification card.

Employer Signature ?JI JL4, Date: 02/25/2018

To: NYS DepL of Labor Foreign labor Certification Unit-H2A State Office Campus Building 12, Room 200 Albany, NY 12240

USDOL-ETA OFLC - Chicago National Processing Cemcr 11 West Quincy Court Chicago, IL 60604

Date: February 25, 2018

From: Story Farms, LLC 4640 Route 32 Catskill, NY 12414

Dear Madam/Sir:

This letter is to inform you that our agent will be: H2Express, Inc, 3007 County Route 20, Hudson, NY 12534. Phone 518-697-5002. Fax 866-210-1791. Cell 518-451-0109 email info@h2expressinc.com Please send all com:spondcnce to them.

Mark Story Manager

Story Farms, LLC 4640 Route 32 Catskill. NY 12414

February 25, 2018

H2A Program Urut USDOL,ETA OFLC, Chicago Natl. Proc. Center 11 West Quincy Court Chicago, IL 60604

RE: Workers' Compensation Policy Assurances

Dear Reviewing Agent:

This letter will certify that we currently have, and will maintain workmen's compensation insurance through the duration of our H2A contract which expires November 30, 2018.

8:JfJ.� MarkStocy �

Manager

.. ............................................................. : ................................... 4.� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ""'

, . STATE OF NEW YORK - WORKERS' COMPENSATION BOARD www.�ny.gov

ESTAOO DE NUEVA YORK-JUNTA DE COMPENSACION OBRERA Sia,ewldeF

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NOTICE OF COMPLIANCE A \/ISO DE CUMPLIMIENTO

J.Q.E.Mf.l.QXf:.fS · A..f.Mf.LE.AQ..QS

IMPORTANT INFORMATION FOR EMPLOYEES WHO ARE INFORMACION IMPORTANTE PARA EMPLEADOS QUE SEAN INJURED OR SUFFER AN OCCUPATIONAL DISEASE WHILE LESIONADOS O SUFRAN UNA ENFERMEDAD OCUPACIONAL •

• • WORKING. MIENTRAS TRABAJAN . . . • • 1. Sy poslin9 this notice and informalioo concemlng your righlS u sn Injured

worker, your employer is inco<npllance wi1h tho Wooccts' Compensa!lcl,n Law. 2. U you dO not nolify your emi,IOyer wilhin 30 days of tho d:110 or your inju,y your claim may oo dlsallOwOd, so do so lmmodialCly, '

• • 3. Yov �(I) emitled to obtain any neeeuary medlC31 1,ea1mon1 311<1 snovld do $0 • • immediately.

: : 4. You may choose any (kictor, pooiattlsl, chir()()(acto, or psycholaoJst rolorrOd • • by a medical doclot' that occcpls NY Stale Workers' Compensallon palienls ' ' aod is Soard autho(ized. Howcve<, II yoo1 cmcJ1oyer Is involved In a certified

prefe,ted pro.;c1e, 01g4nlulion (PPO) you mus, fitsl be lteoted by a p,-oviaor cl'>Q$efl. by 'f')'Jr employe, and yoor employe1 must givo you a written

• , slil(emoot ol your right& concemiog lunher medical care.

: : 5. You ShOuld 1eu your doclot to me copios or modk:al reports coocerning : : yo,.,.< dawn with the WOIUB' Compensation Board er\d wfth your emplOycfs : : insurance company, ...t,icltls indicated at the bottom of this form.

, • 6. You may be entitled IO IOsl Urne benefits W your worl<-relaled lnfury keeps : : 'fO'J rrom � for more ttta" seven days, ccmpets you '° work: at owQr

wages 01 resul\s in permanent disability lo "'Y part of your boOy. You m.iy be enliUect lo �itatio<l senrices ii you neod h<!Jp retu<ning to wortc.

7. You should nol pay any medical providets diteetly, They should MIid U>oir , • bills lo your �oyefs in$Utllnce carrier. II lhCfC 1$ a dispute, Ille ploYlcle< must • • wail until the Board makes a deciS<On bO/o<e ii allempts lo 00hct payment

lrom you. II yov dO nol prnue your claim 01 the So.lrtt rulos tnet )'OIK • : injury is not wori<-n1la1ed. you may be responsi� fo< the payment ol 1119 bo'lls

• • 8. You are entitled to be represented by "" auomoy 01 lic:.nsecl • • representallve. bul � Is not required. U you do• hire a reptue0lal!Ye do not

• • pay him/her cforedly. Any fee Wlll be set by the Boartt and wla be dedUCIO<I h-....m ycu:O\\�.:-d..

• •

, , 9. If you hal/1! dilr,culfy in oblllining a claim ronn or need help in r.a,ng � OIJ1, • ot if you haVe ,ny other queSllons 01 proolems about a jot>-rnlaled i'njury. contact

• : t1l'rf oerice o1 111e WOOOHS' Compensation Board.

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� WORJ(ERS" COlrlPEHSATION BOARD OfflCES • ,..,_,y, 122,1- tOO�s-(86G)TS0-5157 ·BtocliJ)-n. 11201. 1111.Mng,con SI.. Btoollyn • (8001 an-,m

8!ng111n110n. 13901 • Slate Oft'ca Bldg -44 Hawley SL• (866) 902-360,I 8IJffalo, 1•202 -369 Frsnl<in Shel -(866)211� "Hauppauge. 11763. 220 Rabro o,t,,e. StMe 100 • (666) 681-� � 11550· t75F.-iA-·(e66)80S-Jf,30 ._ Yori<. 10021 • 21 s w. uscn SI. • ManNttan • 1aooJ an-1Jn •f>eebldl. 10566 ·, 1 Noc1h Division Sl • (866) 7�$2 ·o.-. lt'32 • 16&-'69111A.,.. • -(ll00)8n-1373 floc!leslet. 1"614 • 130MabSlteetWost•(866)Zll-06'4 S}'Ta<:USAI. 13203 • 935 James Sl • (e66) 8()2.;1730

·DOWWSTATEIIAI.AOORESS�mdlOrthe�.� --and al NYC cff'ices � be mailed to PO Sox 5205 8-lgl\afflton, tlY 13902-52 05

1. Su palrono esiA cumpt.ndo la Loy do Compens.iclon Obrera cuando despliega este comunk:ado concemlentc a sus do,ochos como ttobaJador loSlonado.

2. SI UGled no notiroca Q su patrono denlro det t&mino clc 30 dlas de hllbe1 sulrido $U toslon • w roclamacion podna '"' Ollwslimada. por eso notif,q,,o lnmediatamenlc.

3. Usle<l Ueno domeho a rcclbir cu:ilqu,er lnllomlonto medico noccsario re!aclonlldO con su • lesion y debo !)Mlionarlo lrlmodiatamonto.

4, Paro el tretarnlcnto de cuatqulor leslori o onformedad retoclonadacon el trabajo. uSlod • pucdc cscooor cuotq�r medk:o. podiatrll. qulropractico o pskologo (si cs rofcrido po, un • mod� oulorlzadO) que «ilO aulottzedo y aoopte paclenles do la Juntade Compcosack>n Obr8'11, SUI embargo. sl su p:,trQOO osl!I mitorizlldo a participar urn, organlzaclon cerurrcada do provoodo<es P(elcridos (PPO) usuld dobor& oblcnet 11atamiento lnicial pare , cuolqulor loslOn o enrom)ed.ld rclaclo<lada con el trabajo de la correspondiente • ontldad. P�lronos quo part/clpen on cualqulor de estos p,-ogramas establecid0$ pot ley , estan obllglldosa p(OWJer a sus empl1!aoos noliricac;icln escrita e)(l)licarido sus detechos y obllgll

"c,oocs b.ljo ol p,ogtama a que oi:t6 acogioo.

5. Ustod dober:i requerir de su Medico quo nKlique ooplas de loG lnlorrnes medicos oo su : caso en la Juota do Compcnsar:ioo Obrerl y en la compan!a do s1111u10s de su pairono, que ' se ln<llca at rrna1 de 61a ronna.

6. Ustod Ilene de<echo , �nsaci&, sl au les!On telaelon:ida con et ltObaJO le impode • trabajOr po, m:l.s de sieto dio�. IC obliga • trabajar a sveldo mas bajo o resutta en incapacidad • permanent• � cualqurc,r pane do su CUOIJ)O, Ullod puedo tenet dett<:ho a MMQOS de • rohOllllitacioo sl nocew ayuda � rogresat at t111llajo,

7. No p.,gue a nlnguo pr011eodot mcdlc:o direcbmeota pot tratamiento de su !es& o : enJotmoded retaaonada con el tlabajo. E� doben enviar sus racturas al aseguradot de su : pa110nO. s, el caso es cue�. et proveeoor det>8n espera, ham quo la Junta deCida el caso. lltltff de lnlollf 110$tlon de collto :a'.gullA con!ta 11stad. SI USled no �-am.ta au c:.1so o la • Junta falla que su tui6n o enfermecl.ld no eSl4 reladonada coo el tr�. usted podria ser • responsable dol paoo de tas lac111ras. •

8. No es ObligalOrio el estat �asent:ldo en nlnQllno do los procedlmiel\lOS de la Junta, pe,o • es un der6cho qua usled liene, el eslar teprasentado pot ot,ogado 6 pot repcesenlanle • licendooo sl usled Hi lo desea. SI es rwpresentado. no peoue al abogado o el repn,M<!lanle • lir;ec,d;)do. Cuanoo b Ju<U dOCida IU CAO. los honot8riot; setWI deletminados por ta Junia y dcsalnlados de SUS benefdos.

9. SI Ilene d<oc:ullad en consep un formutJrio de rectamaoon o � ayuda para 11enario , ci Lene dudas SObro cualqular sm,ao&, relaCIOtUl<Sa mn """ lesl6n ci onfermodad COfflUNqU8SO con to ol'r;in;I mu ce<U1n& de ta Junia.

Robert E. Belc4en Chair (Presldcnto)

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. . Worl<e,s' Compensalion Benefi�. wnen duo • ..;u bo pa;ct b-f (Los beneflc:ios do Compensac:loh Obtenl. cuandOs deblclos, seran pagados po,):

THE STATE INSURANCE FUND Name of employer (Nombre de patrono) .. .. 199 Church StrNL N-Y� N. Y. 10CHl7

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(212) 312-9000

• , Effective From __ 1.213112015, (En Vigor Desde)

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. . • : Policy No. ___ L�O.i; l�0-8_: : (Poliza No.)

To cancellation (Hasta cancellation)

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C-105 (08·2009) S. I. F. U..JO

�rfOWR �cow,o,s.t.llON � st_.\tt.Ol�W>Rlt

STORY FARMS LLC 4640 RTE 32

CATSKILL NY 12414

TMIS NOTICE MUST BE POSTED CONSPICIJOIJSL Y IN AND ABOUT TifE EMPLOYER'S PLACE OR PLACES OF BUSINESS.

Failure by ao employer lo post this notice In and about the employer's place o, places of buslooss may result lo a S250 .. penalty fo, each violation.

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