Form Hrp-1034a - Commodity Senior Food Program (Csfp) Individual Notice Of Beneficiary Protections
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1CSFP
Commodity
Senior
Food
Pro
gram
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1034A FORPDF (8-17)
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
INDIVIDUAL NOTICE OF BENEFICIARY PROTECTIONS
DISTRIBUTION INFORMATION
DISTRIBUTION SITE NAME
PHONE NUMBER
ADDRESS (No., Street)
CITY
STATE
ZIP CODE
PROGRAM CONTACT NAME
EMAIL
Because this program is supported in whole or in part by financial assistance from the Federal Government, we are required
to let you know that:
• 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;
• 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;
• We must separate in time or location any privately funded explicitly religious activities from activities supported with
USDA direct assistance;
• 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
• You may report violations of these protections (including denials of services or benefits) by an organization to the
Coordinated Hunger Relief Program at: (602) 771-2788. The Coordinated Hunger Relief Program will respond to the
complaint and report the alleged violations to its respective U.S. Department of Agriculture Food and Nutrition Service
Regional Office ( ).
We must provide you with this written notice before you enroll in our program or receive services from the program, as
required by 7 CFR part 16.
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.
• Disponible en español en línea o en la oficina local.
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