Instructions for AD-2106
Form to Assist in Assessment of USDA Compliance
with Civil Rights Laws
This form is used by USDA agencies, including FSA, NRCS, RBS, RHS, and RUS to gather race,
ethnicity, and gender information from program participants. For participants that are entities,
complete a separate form for each member.
Participants should complete all items.
Fld Name /
1. What is Your Name Enter your full legal name.
2. Legal Residence Enter your current address.
3. Gender Check your appropriate gender.
4. Ethnicity Check your appropriate ethnicity.
5. Race Check your appropriate race(s). Multiple races may be checked.
PRIVACY ACT STATEMENT
The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a - as
amended). The authority for requesting the information identified on this form is the Food, Conservation,
and Energy Act of 2008 (Pub. L. 110-246). The information will be used to compile program application
and participation rate data regarding socially disadvantaged farmers or ranchers and to conduct oversight
and evaluation of civil rights compliance. The information collected on the form may be disclosed to other
Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have
been authorized access to the information by statute or regulation and/or as described in applicable
Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File
(Automated). Providing the requested information is voluntary. However, failure to furnish the requested
information will result in customer declared data not being entered into the database.
The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be
applicable to the information provided. RETURN THIS COMPLETED FORM TO THE
APPROPRIATE USDA SERVICING OFFICE.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on
the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial
status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or
because all or part of an individual’s income is derived from any public assistance program. (Not all
prohibited bases apply to all programs.) Persons with disabilities who require alternative means for
communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s
TARGET Center at (202) 720-2600 (voice and TDD).
To file a complaint of discrimination, write to USDA, Assistant Secretary for Civil Rights, Office of the
Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC
20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642
(English Federal-relay) or (800) 845-6136 (Spanish Federal-relay). USDA is an equal opportunity
provider and employer.