Form AD-3027 "Program Discrimination Complaint Form"

What Is Form AD-3027?

This is a legal form that was released by the U.S. Department of Agriculture on January 19, 2012 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 19, 2012;
  • The latest available edition released by the U.S. Department of Agriculture;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AD-3027 by clicking the link below or browse more documents and templates provided by the U.S. Department of Agriculture.

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Download Form AD-3027 "Program Discrimination Complaint Form"

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AD-3027
OMB Control Number 0508-0002
(1/19/12)
UNITED STATES DEPARTMENT OF AGRICULTURE (USDA)
Office of the Assistant Secretary for Civil Rights
USDA Program Discrimination Complaint Form Instructions
(The complaint form is below the instructions)
PURPOSE:
The purpose of this form is to assist you in filing a USDA program
discrimination complaint.
For help 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.
Incomplete information will delay the processing of your
complaint.
You may also send a complaint by FAX or e-mail. We must have a signed copy of your
complaint, so if you send your complaint by e-mail, be sure to attach the signed copy to
your email.
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. Complaints sent by fax or email will be considered filed on
the day the complaint is faxed or emailed. Complaints filed after the 180-day deadline
must include a ‘good cause’ explanation for the delay. For example, you may have “good
cause” 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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AD-3027
OMB Control Number 0508-0002
(1/19/12)
UNITED STATES DEPARTMENT OF AGRICULTURE (USDA)
Office of the Assistant Secretary for Civil Rights
USDA Program Discrimination Complaint Form Instructions
(The complaint form is below the instructions)
PURPOSE:
The purpose of this form is to assist you in filing a USDA program
discrimination complaint.
For help 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.
Incomplete information will delay the processing of your
complaint.
You may also send a complaint by FAX or e-mail. We must have a signed copy of your
complaint, so if you send your complaint by e-mail, be sure to attach the signed copy to
your email.
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. Complaints sent by fax or email will be considered filed on
the day the complaint is faxed or emailed. Complaints filed after the 180-day deadline
must include a ‘good cause’ explanation for the delay. For example, you may have “good
cause” 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 and in the programs involved. 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 concerns the information requested in this
form 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.
Disclosure is voluntary. However, failure to supply the requested information or to sign
the form may result in dismissal of your complaint. If your complaint is dismissed you
will be notified. The information you provide in this complaint may be disclosed to
outside parties where USDA determines that disclosure is: 1) Relevant and necessary to
the Department of Justice, the court or other tribunal, or the other party before such
tribunal for purposes of litigation; 2) Necessary for enforcement proceedings against a
program that USDA finds to have violated laws or regulations; 3) In response to a
Congressional office if you have requested that the Congressional office inquire about
your complaint or; 4) To the United States Civil Rights Commission in response to its
request for information
.
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)
Office of the Assistant Secretary for Civil Rights
Program Discrimination Complaint Form
First Name:
Middle Initial:
Last Name:
Mailing Address:
City:
State:
Zip code:
E-mail address (if you have one):
Telephone Number starting with area code:
Alternate Telephone Number starting with area code:
Best Time of the Day to Reach You
Best Way to Reach You, (check one): Mail
Phone
E-mail
Other:
Do you have a representative (lawyer or other advocate) for this complaint? Yes
No
If yes, please provide the following information about your representative:
First Name:
Last Name:
Address:
City:
State:
Zip Code:
Telephone:
E-mail:
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):
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Please check () 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?
Use additional pages, if necessary, and please include any
supporting documents that would help show what happened.
3. When did the discrimination occur?
Date:
Month
Day
Year
If the discrimination occurred more than once, please provide the other dates:
Where did the discrimination occur?
4.
Address of location where incident occurred:
Number and street, PO Box, or RD Number
City
State
Zip Code
It is a violation of the law to discriminate against you based on the following: race,
5.
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) Reprisal is prohibited based on
prior civil rights activity.
I believe I was discriminated against based on my
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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
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agency or with a court?
Yes:
No:
If yes, with what agency or court did you file?
When did you file?
Month
Day
Year
Signature:
Date:
Mail Completed Form To:
USDA
Telephone Numbers:
Office of the Assistant Secretary for Civil
Local area: (202) 260-1026
Rights
Toll-free: (866) 632-9992
1400 Independence Ave, SW, Stop 9410
Local or Federal relay: (800) 877-8339
Washington, D.C. 20250-9410
Spanish relay: (800) 845-6136
E-mail address:
Fax: (202)690-7442
program.intake@usda.gov
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