USDA Program Discrimination Complaint Form

OMB Control Number 0508-0002

UNITED STATES DEPARTMENT OF AGRICULTURE (USDA)

Office of the Assistant Secretary for Civil Rights

USDA Program Discrimination Complaint Form

First Name: ______________Middle Initial: _____

Last Name: _______________________________

E-mail address (if you have one):

_______________________________________

Mailing Address:

_______________________________________

(number and street, PO Box, or RD number)

_______________________________________

city state zip code

Telephone Number:

( ) -___________

Alternate Telephone Number:

( ) - ___________

Best Time of the Day to Reach You: _______________________________

Best Way to Reach You: (circle one) Mail Phone E-mail Other: _________________

Do you have a representative (lawyer or other advocate) for this complaint? Yes _____ No_____

If yes, please provide the following information about your representative:

First Name:_____________________________ Last Name:_______________________________

Address:_________________________ City:______________________ State: ____ ZIP Code:____

Telephone: (_____)__________________________E-mail Address:____________________________

1. Who do you believe discriminated against you? Use additional pages, if necessary.

Name(s) of person(s) involved in the alleged discrimination (if known):

_______________________________________________________________________________

Please name the program you applied for (if known/if applicable):

________________________________________________

Please check () the USDA Agency below that conducts the program or provides Federal financial assistance for the program (if known):

 Farm Service Agency  Food and Nutrition Service

 Rural Development  Natural Resource Conservation Service

 Forest Service  Other: __________________________

2. What happened to you? Use additional pages, if necessary, and please include any supporting documents that would help show what happened.

3. When did the discrimination occur?

Date: ___________________

month day year

If the discrimination occurred more than once, please provide the other dates:

___________________________________________________________________________________

4. Where did the discrimination occur?

Address of location where incident occurred:

_______________________________________ (number and street, PO Box, or RD number)

_______________________________________

city state zip code

Property Address (see Instructions on page 4 for explanation):

_______________________________________

(number and street, PO Box, or RD number)

_______________________________________

city state zip code

5. It is a violation of the law to discriminate against you based on the following: race, color, national origin, religion, sex, disability, age, marital status, sexual orientation, family/parental status, income derived from a public assistance program, and political beliefs. (Not all bases apply to all programs. For further information, see Instructions on page 3.) Reprisal is prohibited based on prior civil rights activity.

I believe I was discriminated against based on my _____________________________________________

_____________________________________________________________________________________

5. Remedies: What would it take to resolve this complaint?

_____________________________________________________________________________________

_____________________________________________________________________________________

6. Have you filed a complaint about the incident(s) with another federal, state, or local agency or with a court?

Yes: ______ No: ______

If yes, with what agency or court did you file? ___________________When did you file? _____________

month day year

Signature:_______________________________________________ Date:___________________

Mail Completed Form To:

USDA

Office of the Assistant Secretary for Civil Rights

1400 Independence Ave, SW, Stop 9410

Washington, D.C. 20250-9410

E-mail address: [email protected]

Telephone Numbers:

(202) 260-1026 (Voice)

(866) 632-9992 (Toll-free Customer Service)

(800) 877-8339 (Local or Federal relay)

(866) 377-8642 (Relay voice users)

(202) 619-6853 (Fax)

INSTRUCTIONS

PURPOSE: The purpose of this form is to assist you in filing a USDA program discrimination complaint. For help filling out the form, you may call any of the telephone numbers listed above of this form. You are not required to use this form. You may write a letter; however, it must contain the same information requested in this form. You or your representative must sign and date your letter. You may also send a complaint by FAX or electronic mail. If you send a complaint by electronic mail, you must scan in the signature. Incomplete information will delay the processing of your complaint.

FILING DEADLINE: A program discrimination complaint must be filed not later than 180 days of the date you knew or should have known of the alleged discrimination, unless the time for filing is extended by USDA. Complaints filed after the 180-day deadline must include a ‘good cause’ explanation for the delay. For example, you may have “good cause” if:

(1) You could not reasonably have been expected to know of the discriminatory act within the 180-day period;

(2) You were seriously ill or incapacitated;

(3) The same complaint was filed with another Federal, state, or local agency, and that agency failed to act on your complaint.

USDA POLICY: Federal law and policy prohibits discrimination against you based on the following: race, color, national origin, religion, sex, disability, age, marital status, sexual orientation, family/parental status, income derived from a public assistance program, and political beliefs. (Not all bases apply to all programs. USDA will determine if it has jurisdiction under the law to process the complaint on the basis(es) identified and in the program(s) involved.) Reprisal is prohibited based on prior civil rights activity.

PROPERTY ADDRESS: This information is to be filled out for some farm and housing complaints where a piece of property is involved. For example, the property address may be 1) the location of your farm; or 2) the location of a rental property where you lived or where you applied for an apartment.

***PLEASE READ IMPORTANT LEGAL INFORMATION BELOW***

CONSENT

This USDA Program Discrimination Complaint Form is provided in accordance with the Privacy Act of 1974, 5 U.S.C. §552a, and concerns the information requested in this form to which this Notice is attached. The United

States Department of Agriculture’s Office of the Assistant Secretary for Civil Rights (USDA) requests this information pursuant to 7 CFR Part 15. If the completed form is accepted as a complaint case, the information collected during the investigation will be used to process your program discrimination complaint. Disclosure is voluntary. However, failure to supply the requested information or to execute the form may render your complaint dismissed. The information provided may be disclosed to outside parties where USDA determines that disclosure is (1) relevant and necessary to the Department of Justice, the court or other tribunal, or the other party before such tribunal for purposes of litigation (2) necessary for enforcement proceedings against a program that USDA finds to have violated the laws or regulations (3) to a Congressional office from the record of an individual in response to an inquiry from the Congressional office made at the request of that individual or (4) to the United States Civil Rights Commission in response to its request for information.

REPRISAL (RETALIATION) PROHIBITED:

No Agency, officer, employee, or agent of the USDA, including persons representing the USDA and its programs, shall intimidate, threaten, harass, coerce, discriminate against, or otherwise retaliate against anyone who has filed a complaint of alleged discrimination or who participates in any manner in an investigation or other proceeding raising claims of discrimination.

PAPERWORK REDUCTION ACT AND PUBLIC BURDEN STATEMENTS:

The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.) requires us to inform you that this information is being collected to ensure that your complaint contains all the information required to file a complaint. The Office of the Assistant Secretary for Civil Rights will use the information to process your complaint of program discrimination. Response to this request is voluntary. The information you provide on this form will only be shared with persons who have an official need to know, and will be protected from public disclosure pursuant to the provisions of the Privacy Act, 5 U.S.C. § 552a(b). The estimated time required to complete this form is 60 minutes. You may send comments regarding the accuracy of this estimate and any suggestions for reducing the time for completion of the form to USDA, Office of the Assistant Secretary for Civil Rights, 1400 Independence Ave, SW, Washington, DC 20250-9410.

An Agency may not conduct or sponsor, nor is a person required to respond to, a collection of information unless it displays a currently valid OMB Control Number. The OMB Control Number for this form is 0508-0002.