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Complaint Form

 

To file a complaint, complete this form and submit it to Lauren Arenas, Food Director @ 830-254-3551, or Falls City ISD, PO Box 399, Falls City, TX 78113. All complaints, written or verbal, are automatically forwarded to the Texas Department of Agriculture.

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  1. Contact Information for Person Submitting the Complaint

(Please record your name, address, telephone number, and additional contact information in the spaces below.)

 

First Name

 

Middle Initial

 

Last Name

 

 

 

Address

 

City, State, and Zip Code

 

Best Telephone Number for You

 

 

 

Are there other ways we can contact you? (If yes, list them in the box. Other ways might include an email address or a different telephone number.)

 

 

 

 

 

 

 

 
  1. Reason for the Complaint

(Provide information about the complaint with as much detail as possible for questions (A-E). Attach additional paper if more space is needed.)

 
  1. What is the name and address of the entity you are filing the complaint about?

 

 

 

 

 

 

 

 

 

 

 

 
  1. If this complaint is against an individual, enter the person (or persons) name and contact information in this box. If the complaint is not against an individual, record a check in the box in front of N/A.

 N/A—This complaint is not against an individual.

 

 

 

 

 

 

 

 

 

 

 

 
  1. Describe the complaint with as much detail as possible, including the date and time incident occurred. If you have any relevant documentation that supports the complaint or alleged violation, attach that documentation to this form.

 

 

 

 

 

 

 

 

 

 

 
  1. If there are other people who have knowledge about this event, please provide their names, titles, and address/contact information. (Attach additional sheets if you need more space.)

 

Name

Title

Address/Contact Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
  1. What is the basis or the type of discrimination you feel occurred? If the complaint is not based on discrimination, record a check in the box in front of N/A.

 N/A—This complaint is not based on discrimination.

(Check the boxes that apply.)

 Race

  Sex

  Color

  Age

  National Origen

  Disability

Signature of Complainant

 

 

Date:

 

 

 

 

 -----This Space to Be Completed by Person Receiving the Complaint -----

 

Name of Person Receiving Complaint:

 

 Complaint was translated (Check this box if this complaint from was completed by a person other than the complainant)

 

 

Staff Person Assigned to Address Complaint:

 

Date Forwarded to the Texas Department of Agriculture:

 
                 

 

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: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. This institution is an equal opportunity provider.



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