SENIOR FARMERS’ MARKET NUTRITION PROGRAM
SELF DECLARATION FORM
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.
file a program complaint of discrimination, complete the USDA Program
DiscriminationComplaint Form, (AD-3027) found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, 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.
http://www.fns.usda.gov/wic/wic-income-eligibility-guidelines
USDA is an Equal Opportunity Provider, Employer and Lender
Federal Register / Vol. 84, No. 81 / Friday , April 26, 2019 / Notices
