Form Hrp-1030a - Commodity Senior Food Program (Cfsp) Civil Rights Complaint / Grievance
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1
2
3CSFP
Commodity
Senior
Food
Pro
gram
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1030A FORPDF (8-17)
Page 1 of 3
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
CIVIL RIGHTS COMPLAINT / GRIEVANCE
COMPLAINANT INFORMATION
NAME (Last, First, M.I.)
DATE
ADDRESS (No., Street)
CITY
STATE
ZIP CODE
HOME PHONE NUMBER
CELL PHONE NUMBER
EMAIL
TYPE OF DISCRIMINATION:
Race
Color
National Origin
Sex
Age
Disability
Reprisal or Retaliation
STATUS OF PERSON FILING COMPLAINT / GRIEVANCE:
Individual
Organization
Employee
Other:
STATEMENT OF COMPLAINT / GRIEVANCE
(Include type of discrimination charged and the specific incident and date(s) in which it occurred)
Routing (send one copy to):
Agency/Civil Rights Coordinator
Department of Economic Security / Coordinated Hunger Relief Program
1789 West Jefferson Street, Mail Drop 6282
Phoenix, AZ 85007
Lhamman@azdes.gov
(Keep original for your records)
You may also send a discrimination
(1) mail: U.S. Department of Agriculture
complaint directly to:
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442;
(3) email: program.intake@usda.gov
You may also call:
DES/Coordinated Hunger Relief Program (602) 771-2788; or
DES/ADA Liaison (602) 771-7500
AGENCY CIVIL RIGHTS OFFICE USE ONLY
09/13/2017
DATE COMPLAINT RECEIVED
COMPLAINT NUMBER
AGENCY LOCATION OF INCIDENT
NAME OF PERSON RECEIVING COMPLAINT
SIGNATURE
See page 3 for USDA nondiscrimination and EOE/ADA/LEP/GINA statements
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