Form Hrp-1025a - Written Notice Of Beneficiary Rights printable pdf download

THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP)

Written Notice of Beneficiary Rights

Name of Organization:

Contact Information for Program Staff:

Name:

Phone Number:

Email Address:

Because TEFAP is supported in whole or in part by financial assistance from the Federal Government, we are required

to let you know that:

1) We may not discriminate against you on the basis of religion or religious belief, a refusal to hold a religious belief, or a

refusal to attend or participate in a religious practice;

2) We may not require you to attend or participate in any explicitly religious activities that are offered by us, and any

participation by you in these activities must be purely voluntary;

3) We must separate in time or location any privately funded explicitly religious activities from activities supported with

USDA direct assistance;

4) If you object to the religious character of our organization, we must make reasonable efforts to identify and refer you to an

alternate provider to which you have no objection. We cannot guarantee, however, that in every instance, an alternate

provider will be available; and

5) You may report violations of these protections (including denials of services or benefits) by an organization to the State

agency ( ). The State agency will respond to the complaint and report

the alleged violations to their respective USDA FNS Regional Office ( ).

We must provide you with this written notice before you enroll in TEFAP or receive services from TEFAP, as required by

7CFR part 16.

State Agency Contact Information:

Arizona Department of Economic Security

Coordinated Hunger Relief Program

1789 West Jefferson Street  Mail Drop 3784

Phoenix, AZ 85007

(602) 771-2788  coordinatedhungerreliefprogram@azdes.gov

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, disability, age, 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.

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with

Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic

Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or

employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this document in alternative format

or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is

available upon request. Ayuda gratuita con traducciones relacionadas con los servicios del DES esta disponible a solicitud del cliente. Disponible en

español en línea o en la oficina local.

HRP-1025A POSNA (6-16)