Fill - Free fillable USDA Program Discrimination Complaint Form Instructions (USDA) PDF form

AD-3027

(1/19/12)

OMB Control Number 0508-0002

UNITED STATES DEPARTMENT OF AGRICULTURE (USDA)

USDA Program Discrimination Complaint Form Instructions

(The complaint form is below the instructions)

PURPOSE: This form may be used if you believe you have been subjected to

discrimination in any USDA program or activity and you wish to file a complaint of

discrimination. The form can be used to file a complaint of discrimination based on race,

color, national origin, religion, sex, disability, age, marital status, sexual orientation,

family/parental status, income derived from public assistance program and political

beliefs. If you need assistance filling out the form, you may call any of the telephone

numbers listed at the bottom of the complaint form. You are not required to use

the complaint form. You may write a letter instead. If you write a letter it must

contain all of the information requested in the form and be signed by you or your

authorized representative.

You may also send a complaint by FAX or United States Postal Service Mail. We must

have a signed copy of your complaint. Incomplete information or an unsigned form

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 sent by

mail are considered filed on the date the complaint was signed, unless the date on

the complaint letter differs by seven days or more from the postmark date, in which

case the postmark date will be used as the filing date. Complaint documentation or

Complaint Forms sent by fax or mail will be considered filed on the day the complaint is

faxed or mailed. Complaints filed after the 180-day deadline must include a ‘good

cause’ explanation for the delay. For example, 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).

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USDA will determine if it has jurisdiction under the law to process the complaint on

the bases identified in the complaint and in the programs indicated in the complaint.

Reprisal that is based on prior civil rights activity is prohibited.

PROPERTY ADDRESS: If this complaint involves a farm or other real estate property

that is not your current address, write in the address for that farm or real estate

property. Otherwise, this part of the form can be left blank.

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 is used to provide the

information 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.

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.

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OMB Control Number 0508-0002

UNITED STATES DEPARTMENT OF AGRICULTURE (USDA)

Program Discrimination Complaint Form

First Name: Middle Initial: Last Name:

Provide Your Full Mailing Address

Number and Street, PO Box, Road, or Route:

Apartment Number (if applicable):

City, State and Zip Code:

Email Address:

Telephone Number (with area code):

Alternate Telephone (with area code):

Best Way to Reach You (select one)

Mail: Phone: E-mail: Other:

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

Yes: No:

If Yes is selected, please provide the following information about your representative:

Representative First Name: Last Name:

Number and Street, PO Box, Road or Route:

Apartment Number:

City, State and Zip Code:

Telephone: Email:

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 select 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? State the date when the alleged discrimination occured

and then describe what happened. If the alleged discrimination occurred more

than once, please provide the other dates and describe what happened. Use

additional pages, if necessary, and please include any supporting documents that

would help show what happened.

3. Where did the discrimination occur?

Address of location where incident occurred:

Number, Street, PO Box, Road, Route

City

State

Zip Code

4. 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, family/parental

status, income derived from a public assistance program, and political beliefs. (Not

all bases apply to all programs) Reprisal is prohibited based on prior civil rights

activity.

I believe I was discriminated against based on my

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5. Remedies: How would you like to see this complaint resolved?

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 Ye

a

r

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

Telephone Numbers:

Local area: (202) 260-1026

Toll-free: (866) 632-9992

Local or Federal relay: (800) 877-8339

Spanish relay: (800) 845-6136

Fax: 1-833-256-1665

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click to sign

signature

click to edit

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.

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Fillable USDA Program Discrimination Complaint Form Instructions (USDA)

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