Form Fa-001 - Application For Benefits (Page 27 of 31) in pdf

Form Fa-001 - Application For Benefits Page 27

Do you need help with this application? Visit

or call 1-855-HEA-PLUS (432-7587).

Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service

at (800) 877-8339; or (800) 845-6136 (Spanish).

For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either

contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish, or call the State Information/Hotline

Numbers line (the listing of hotline numbers by State can be found online at

To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S. Department

of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue,

S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (800) 537-7697 (TTY).

USDA and HHS are equal opportunity providers and employers.

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. The Department must make a reasonable accommodation to allow a person with a disability to take

part in a program, service or activity. For example, this means if necessary, the Department must provide sign language

interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the

Department will take any other reasonable action that allows you to take part in and understand a program or activity,

including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a

program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To

request this document in alternative format or for further information about this policy, contact your local office manage

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.

OFFER OF VOTER REGISTRATION FORM

The Offer of Voter Registration form is the last page.

Please read it, answer “Yes” or “No”, sign where it

says “Signature of Client”, and date it.

FA-001 (12-17)

Page 18

Form Fa-001 - Application For Benefits Page 27