AD 3027 Program Discrimination Complaint Form

AD-3027

OMB Control No: 0508-0002
Expiration Date: 05/30/2027

U.S. Department of Agriculture

USDA Program Discrimination Complaint Form
Complainant Information
Middle Initial
Last Name

First name

Mailing Address (Include Full City, State and Zip Code)
Primary Phone Number
Best way to reach you:

Alternate Phone Number
□ Mail

□ Phone

Email
□ Email

□ Other

If you have difficulty understanding the English language, you may request language assistance services by calling
866-632-9992. Assistance will be available for individuals who are not proficient in English. Persons with disabilities who
require alternative means of communication (e.g., braille, large print, American Sign Language) should contact the
responsible State or local Agency that administers the program or contact the United States Department of Agriculture
(USDA) through the Federal Telecommunications Relay Service at 711 (voice TTY).
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 (Include Full City, State and Zip Code)
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.
□ Agricultural Marketing Service, AMS
□ Foreign Agricultural Service, FAS/Trade and Foreign Agricultural Affairs, TFAA
□ Food and Nutrition Service, FNS
□ Forest Service, FS
□ Farm Service Agency, FSA
□ National Institute of Food and Agriculture, NIFA
□ Natural Resources Conservation Service, NRCS
□ Rural Development, RD
□ Other
□ Unknown
3. Date of recent alleged discrimination
4. Location and/or address of the office where discrimination occurred
(mm/dd/yyyy)

5. Who do you believe discriminated against you? Include the name(s) of person(s) involved in the alleged
discrimination (if known).

AD-3027

OMB Control No: 0508-0002
Expiration Date: 05/30/2027

U.S. Department of Agriculture

USDA Program Discrimination Complaint Form
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:
□ Race

□ Sex

□ Marital Status

□ Sexual Orientation

□ Gender Identity (Expression)

□ Color

□ Disability

□ Family/Parental Status

□ National Origin

□ Age

□ Income from Public Assistance

□ Political Beliefs

□ Religion

□ Retaliation (prior civil rights activity)

8. How would you like to see this complaint resolved?

Remedies

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?

Complainant Signature

Date

11. If yes, when did you file?
(mm/dd/yyyy)

Representative Signature

Date

OMB Control No: 0508-0002
Expiration Date: 05/30/2027
INSTRUCTIONS
PURPOSE: The Agriculture Department 3027(AD 3027) Program Discrimination Complaint Form may be used to
file a complaint 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 (including limited English proficiency), 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. You may also use this form to file a program complaint alleging an adverse environmental impact to
your health or the environment of a protected group caused by the program or activities of USDA, its Mission Areas
or agencies.
You are not required to use this form to file a discrimination complaint, you may send a letter or email instead of this
form. The letter or email must include the information requested in items 1-11 on this form. If you decide to use this
form, please type or print all information in items 1-11 of this form and use additional pages if more space is needed.
If you need assistance completing this form, call 866-632-9992.
Pursuant to 7 CFR 16.4(d), beneficiaries and prospective beneficiaries in programs supported by indirect financial
assistance from USDA may file written complaints with USDA alleging violations of the rule’s religious freedom
protections by contacting or filing a written complaint with USDA’s Office of the Assistant Secretary for Civil Rights
(OASCR).
If you need assistance filling out this form (including translation services), you may call (866) 632-9992; assistance
will be available in English and for individuals who are not proficient in English or in other languages. Persons with
disabilities who require alternative means of communication for program information (e.g., Braille, large print, and
American Sign Language) should contact the responsible State or local Agency that administers the program or
contact USDA through the Telecommunications Relay Service at 711 (voice and TTY)
We must have a signed copy of your complaint. An incomplete or unsigned form or letter will delay
processing 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 is received by USDA. Complaint documentation or Complaint
Forms sent by email will be considered filed on the date the complaint is received. Complaints filed after the 180-day
deadline must include a ‘good cause’ explanation for the delay. For example, if:
You could not reasonably have been expected to know of the discriminatory act within the 180-day period;
You were seriously ill or incapacitated; or
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 prohibit discrimination against you based on race, color, and national origin
includes discrimination based on shared ancestry or ethnic characteristics or based on citizenship in a country with a
dominant religion. Discrimination based on race, color, and national origin also includes discrimination, including
harassment, because you and/or another individual are, for example, Jewish, Muslim, Arab, Hindu, or Sikh; or based on
other ethnic and religious characteristics. For example, individuals who have been subjected to ethnic slurs (such as
antisemitic or anti-Muslim harassment); harassed for how they look, dress, or speak in ways related to their ethnic
background (such as skin color, religious attire, or language spoken); or stereotyped based on their perceived ethnic
characteristics. USDA will determine if it has jurisdiction under the law to process the complaint on the basis identified in
the complaint and in the programs indicated in the complaint. Reprisal that is based on prior civil rights activity is
prohibited.
1.
2.
3.

OMB Control No: 0508-0002
Expiration Date: 05/30/2027
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, Mail Stop 9410, Washington, DC 20250-9410.
e-Mail: program.intake@usda.gov.
For more information visit: 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) and is used to solicit information for processing complaints of discrimination. USDA 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.
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. §§ 794; 794d) and any other antidiscrimination 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: More information on the routine uses for the system can be found in the System of Records Notice
USDA-2021-0007 records maintained by OASCR can be seen via the internet at https://www.usda.gov/home/privacypolicy/system-records-notices.
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. OASCR 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, SW,
Mail Stop 9410, 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.

OMB Control No: 0508-0002
Expiration Date: 05/30/2027
TITLE VI AND ENVIRONMENTAL JUSTICE
Title VI of the Civil Rights Act of 1964 requires federal agencies to ensure that programs or activities receiving
federal funding, including those that affect human health or the environment, do not use discriminatory criteria,
methods, or practices that adversely impact protected groups. USDA is advancing environmental justice by carrying
out its responsibilities under the law to identify and address disproportionate and adverse public health and
environmental, climate-related, and cumulative impacts on communities with environmental justice concerns. USDA
invites the public to bring to its attention possible violations of our nation's environmental laws. Please use this form
to let the USDA know of any environmental, health and climate impacts on individuals and communities that may be
caused by the activities of USDA, its Mission Areas or agencies. Please understand that submitting this complaint
form has no effect on any statute of limitations or other filing requirements that might apply to any complaint you may
have. Further, by submitting this complaint you have not commenced a lawsuit or other legal proceeding, and this
office has not initiated a lawsuit or proceeding on your behalf.
NATIONAL ORIGIN DISCRIMINATION
Discrimination based on national origin includes discrimination based on the country, world region, or place where a
person or their ancestors come from; a person's limited English proficiency or English learner status; and a person's
actual or perceived shared ancestry or ethnic characteristics, including membership in a religion that may be
perceived to exhibit such characteristics (e.g., Hindu, Jewish, Muslim, and Sikh students).
USDA ACCESSIBILITY STATEMENT
Section 508 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794d) authorizes individuals to file
administrative complaints and civil actions against the Department, limited to the Department’s alleged failure to
procure accessible technology. The statute requires federal agencies to process Section 508 complaints according
to the same complaint procedures used to process Section 504 complaints. USDA is committed to making its digital
content accessible. USDA customers, employees, job applicants, and members of the public with disabilities must
have access to information and communication technology (ICT) comparable to the access available to those
without disabilities.