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* 1. Your contact Information

Please complete the following demographic questions. The answers you provide will not affect your eligibility for the SFMNP. Standards for eligibility and participation in the SFMNP are the same for everyone, regardless of race, color, national origin, age, disability, or sex. I understand that I may appeal any decision made by the local agency regarding my eligibility for the SFMNP.

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* 2. Ethnicity - Are you Hispanic/Latino?

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* 3. Race (select one or more)

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* 5. Have you received SFMNP Checks from any other location this year?

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* 6. Verification

Complaint Process: Civil Rights Violations

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and employees, and

institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
 
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form (AD-3027) found online at

http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
  1. Mail:
USDA
Office of the Assistant Secretary for Civil Rights
400 Independence Avenue, SW
Washington, D.C. 20250-9410;
  1. Fax: (202) 690-7442; or
  2. Email: program.intake@usda.gov
This institution is an equal opportunity provider

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