VA_Written Noticemof Beneficiary Rights and Referral Req

OMB No. 2900-0828

Written Notice for Beneficiaries

U.S. DEPARTMENT OF VETERANS AFFAIRS

Name of Organization:

Name of Program:

Contact information for Program Staff (name, phone number, and e-mail address, if appropriate):

­­­­­­­­­­­­­­­­_____________________________________

_____________________________________

_____________________________________

Because this program is supported in whole or in part by financial assistance from the Federal Government, we are required to let you know that—

• We may not discriminate against you on the basis of religion, religious belief, refusal to hold a religious belief, or a refusal to attend or participate in a religious practice;

• We may not require you to attend or participate in any explicitly religious activities that are offered by us, and any participation by you in such activities must be purely voluntary;

• We must separate in time or location any privately funded explicitly religious activities from activities supported with direct Federal financial assistance;

• If you object to the religious character of our organization, we must make reasonable efforts to identify and refer you to an alternative provider to which you have no objection; we cannot guarantee, however, that in every instance an alternate provider will be available; and

• You may report violations of these protections including any denials of services or benefits to VA or the awarding entity.

We must give you this written notice before you enroll in the program or receive services from the program.

BENEFICIARY REFERRAL REQUEST

If you object to receiving services from us based on the religious character of our organization, please complete this form and return it to the program contact identified above. If you object, we will make reasonable efforts to refer you to another service provider. With your consent, we will follow up with you or the organization to which you were referred to determine whether you contacted that organization.

Please check all that apply

( ) I want to be referred to another service provider.

( ) Please follow up with me or the service provider to which I was referred.

Name:

Best way to reach me (phone/address/email):

( ) Please do not follow up.

Beneficiary Name (print):

___________________________________________

Beneficiary Name (sign)

Date:

The Paperwork Reduction Act: This information collection is in accordance with the clearance

requirements of section 3507 of the Paperwork Reduction Act of 1995. Public reporting burden

for this collection of information 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 information. Respondents should be

aware that notwithstanding any other provision of law, no person shall be subject to any penalty

for failing to comply with a collection of information if it does not display a currently valid

OMB control number.