AD-3027                                                                                                                                 OMB Control Number: 0508-0002 Expiration Date: 05/31/2024

U.S. Department of Agriculture USDA Program Discrimination Complaint Form

Complainant Information
	
First name
	Middle Initial
	Last Name
	
Mailing Address
	
Primary Phone Number
	Alternate Phone Number
	Email
	
Best way to reach you:	□Mail	□Phone	□Email	□Other
	
Representative Information
	
Do you have a representative?	□Yes	□No
	Do you have written authorization from representative?
If so, please attach.	□Yes	□No
	
First name
	Last Name
	
Mailing address
	
Phone
	Email
	
Complaint Information
(attach additional pages and supporting documentation as needed)
	
1. Provide the name of the program you applied for (if known/applicable).
	
2. Select the USDA agency that conducts the program or provides Federal financial assistance for the program.
□FNS	□FS	□FSA	□RD	□NRCS	□Other	□Unknown
	
3. Date of recent alleged discrimination (mm/dd/yyyy)
	4. Location and/or address of the office where discrimination occurred
	
5. Who do you believe discriminated against you? Include the name(s) of person(s) involved in the alleged discrimination (if known).
	
6. What happened to you? (please include dates of each allegation)
	
7.It is a violation of the law to discriminate against you based on the following: race, color, national origin, religion, sex (including gender identity and expression), sexual orientation, 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:
	
Remedies
	
8. How would you like to see this complaint resolved?
	
9. Have you filed a complaint about the incident(s) with another federal, state, or local agency or with a court?
	
10. If yes, with what agency or court did you file?
	11. If yes, when did you file? (mm/dd/yyyy)

Complainant Signature	Date	Representative Signature	Date

OMB Control Number: 0508-0002 Expiration Date: 05/31/2024

INSTRUCTIONS
	
PURPOSE:This form may be used if you believe you have experienced 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 (including gender identity and expression), sexual orientation, disability, age, marital status, 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.

We must have a signed copy of your complaint. Incomplete information or an unsigned form will delay the process of your complaint

FILING DEADLINE:A program discrimination complaint must be filed within 180 days from 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; or
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 (including gender identity and expression), sexual orientation, disability, age, marital status, 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 bases identified in the complaint and in the programs indicated in the complaint. Reprisal that is based on prior civil rights activity is prohibited.
	
OFFICE LOCATION WHERE DISCRIMINATION OCCURED:List the location and/or address of the office where discrimination occurred. If not known, this part of the form can be left blank.
	
WHERE TO FILE YOUR COMPLAINT: You may submit your completed form or letter to USDA by:
Mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence, Ave, SW, STOP 9410, Washington, DC 20250-9410;
Fax: 1 (833) 256-1665 or (202) 690-7442; or e-Mail: program.intake@usda.gov.

You may also visit our website at:https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complaint.
	
LEGAL INFORMATION
	
CONSENT: This USDA Program Discrimination Complaint Form is provided in accordance with the Privacy Act of 1974 (5 U.S.C. §552a),andis used to solicit information for processing complaints of discrimination. The United States Department of Agriculture’s Office of the Assistant Secretary for Civil Rights (OASCR) requests this information pursuant to 7 CFR Part 15.

If the completed form is accepted as a complaint, 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.
	
PRIVACY ACT STATEMENT( 5 U.S.C. § 552a)
	
AUTHORITIES: Collection of this information is authorized by Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d); and Sections 504 and 508 of the Rehabilitation Act of 1973 (29 U.S.C. §§ 790-790f) and any other anti-discrimination statutes, rules and regulations.
	
PURPOSE: The information solicited on this form is used for processing complaints of discrimination under the statutes listed in the "Authorities" section of this notice. Any information obtained from this form will be maintained in our system of record.
	
ROUTINE USES: To respond to requests from individuals and agencies outside the Department (such as the White House, Congress, and the Equal Employment Opportunity Commission) regarding the status of a complaint. More information on the routine uses for the system can be found in the System of Records Notice USDA-2021-0007 records maintained by the OASCR.
	
DISCLOSURE: Providing this information is voluntary. Failure to complete this form may lead to a delay in processing of the complaint or rejection of the complaint due to an inadequate information to continue processing.
	
PAPERWORK REDUCTION ACT STATEMENT

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 process it fully. The Office of the Assistant Secretary for Civil Rights will use the information to process your discrimination complaint.

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 the U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, Mail Stop 9410, Washington, DC 20250. 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.