AD-2106 Approved OMB No. 0503-0019
U.S. Department of Agriculture
Form to Assist in Assessment
of USDA Compliance With Civil Rights Laws
The purpose of this questionnaire is to gather race, ethnicity, and gender information about persons who
apply and participate in this USDA program. The information you provide will not be used when
reviewing your application or when determining whether you are eligible to participate in this program.
This is a voluntary questionnaire. You are not required to give this information, but we hope you will
because the information you give will be used to improve the operation of this program, to help USDA
design additional opportunities for program participation, and to monitor enforcement of laws that require
equal access to this program for eligible persons. If you have previously provided this information to
USDA please DO NOT fill out this form. Your information will be kept private to the extent permitted
by law. Thank you for your response.
1. What is your name?
2. Legal Residence:
3. What is your gender? Male Female
Please answer BOTH question 4 and question 5 below about ethnicity and race. For this questionnaire,
Hispanic or Latino origins are not races.
4. Ethnicity: Hispanic or Latino
Not Hispanic or Latino
5. What is your race? Mark all that apply.
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
According to the Paperwork Reduction Act of 1995, an agency may not conduct, and a person is not required to respond to, a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0503-0019. The
time required to complete this information collection is estimated to average 2 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
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 /
Item No.
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.
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
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 individuals 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 USDAs
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.