Application For Food Distribution Form - 2013 (Page 7 of 8) in pdf

Application For Food Distribution Form - 2013 Page 7

USDA FNS NON-DISCRIMINATION STATEMENT

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil

rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions

participating in or administering USDA programs are prohibited from discriminating based on

race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or

retaliation for prior civil rights activity in any program or activity conducted or funded by

USDA.

Persons with disabilities who require alternative means of communication for program

information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact

the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of

hearing or have speech disabilities may contact USDA through the Federal Relay Service at

(800) 877-8339. Additionally, program information may be made available in languages other

than English.

To file a program complaint of discrimination, complete the

USDA Program Discrimination

Complaint

Form, (AD-3027) found online at:

, and at any USDA office, or write a letter

addressed to USDA and provide in the letter all of the information requested in the form. To

request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter

to USDA by:

(1)

mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW

Washington, D.C. 20250-9410;

(2)

fax: (202) 690-7442; or

(3)

email:

program.intake@usda.gov.

This institution is an equal opportunity provider.

Application For Food Distribution Form - 2013 Page 7