What you
Call Your
WIC Clinic if...
What WIC
can expect
expects of you
BREASTFEEDING SUPPORT
& NUTRITION EDUCATION
To help you feed your family
in a healthy way.
HONESTY
n Do not break WIC rules. This can
result in you being taken off the
WIC program, having to pay back
money and/or facing legal charges.
n Do not hide facts or provide
false information to WIC.
n Never return WIC foods
for cash or credit.
n Never accept cash or credit
for WIC vouchers.
n Never sell or trade your
WIC vouchers or WIC food.
INFORMATION
About health care, immunizations,
and other programs.
WIC FOODS
Healthy foods for each participant.
n
n
n
n
n
You have questions about your next appointment.
You have questions about nutrition or breastfeeding.
Your vouchers are lost or stolen.
Your name, address or phone number changes.
You have comments or concerns. Your feedback is important to us.
NAME OF LOCAL WIC AGENCY
WIC LOCAL AGENCY PHONE NUMBER
KEEP APPOINTMENTS
n Please call your WIC Clinic
if you need to reschedule.
COMMON COURTESY
n Treat WIC and store staff
with respect and courtesy.
EQUAL TREATMENT
We treat you the same no matter
your race, color, age, national
origin, disability, or sex.
FAIRNESS
You may ask for a hearing if you do
not agree with WIC staff about your
eligibility for WIC.
Bring your WIC ID Folder every time
you go to the WIC Clinic or grocery store.
USE WIC VOUCHERS CORRECTLY
n Get vouchers from only one
WIC Clinic at a time.
n Shop at WIC-approved stores
in Minnesota only.
n Buy only the foods listed on the
voucher and Shopping Guide.
n Use vouchers on or between the
dates listed on each voucher.
n Sort WIC foods by voucher. Separate
WIC foods from non-WIC items
when checking out at the store.
Keep this
WIC ID
Folder
Always
bring this
WIC ID Folder
with you…
To your
WIC appointments
(along with your picture ID).
n
To the grocery store.
n
If you move.* (See back of brochure.)
HOUSEHOLD ID#
Moving to Another State*
n
n
n
PEOPLE AUTHORIZED TO PICK UP AND USE WIC VOUCHERS:
Please make sure everyone listed knows the WIC program rules.
Your WIC benefits will continue there!
Tell us. We’ll give you a transfer notice to take with you before you leave.
If you don’t have the notice before leaving, just take your WIC ID
folder to the new WIC agency. They can call us.
PARTICIPANT/PARENT/GUARDIAN
SIGNATURE
NAME
Questions about WIC Foods
REPORT WIC FRAUD OR ABUSE
n If you know of any store or person
who is buying, selling or otherwise
misusing WIC foods or benefits,
please contact us by email at
[email protected] or
by phone at 1-800-657-3942.
NAME
SIGNATURE
IfyouhavequestionsaboutWICfoods or trouble finding
WIC foods, call the state WIC office at 1-800-657-3942.
NAME
You can also visit the Minnesota Department of Health Website
at www.health.state.mn.us/wic
SIGNATURE
2017-2018 09/16 ID 53885
Delivery Date:_______ /_______ /_______
_______ /_______ /_______
Due Date:
_______ /_______ /_______
DOB:
Delivery Date:_______ /_______ /_______
_______ /_______ /_______
Due Date:
_______ /_______ /_______
DOB:
Delivery Date:_______ /_______ /_______
_______ /_______ /_______
Due Date:
_______ /_______ /_______
DOB:
Delivery Date:_______ /_______ /_______
_______ /_______ /_______
Due Date:
_______ /_______ /_______
DOB:
Delivery Date:_______ /_______ /_______
_______ /_______ /_______
Due Date:
_______ /_______ /_______
DOB:
Delivery Date:_______ /_______ /_______
of participant(s)
Name
_______ /_______ /_______
Due Date:
_______ /_______ /_______
DOB:
or Deliverydate
WICID#
DOB,DueDate
State
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
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______ /_______ /______
______ /_______ /______
______ /_______ /______
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______ /_______ /______
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______ /_______ /______
______ /_______ /______
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______ /_______ /______
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______ /_______ /______
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______ /_______ /______
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______ /_______ /______
______ /_______ /______
______ /_______ /______
begin date
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______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
date mid-cert completed
CertificationPeriod
end date
Information
Additional
Interpreter needed/language:
Clinic
Clinic ID#
Agency ID#
n
WIC ID Folder
KEEP WIC VOUCHERS SAFE
n Handle WIC vouchers carefully.
n Report lost or stolen vouchers
immediately.
n Lost or stolen vouchers
might not be replaced.
n Never use WIC vouchers
reported lost or stolen.
Last date of income determination (migrant only)
/
/
What you
Call Your
WIC Clinic if...
What WIC
can expect
expects of you
BREASTFEEDING SUPPORT
& NUTRITION EDUCATION
To help you feed your family
in a healthy way.
HONESTY
nDo not break WIC rules. This can
result in you being taken off the
WIC program, having to pay back
money and/or facing legal charges.
nDo not hide facts or provide
false information to WIC.
n Never return WIC foods
for cash or credit.
n Never accept cash or credit
for WIC vouchers.
n Never sell or trade your
WIC vouchers or WIC food.
INFORMATION
About health care, immunizations,
and other programs.
WIC FOODS
Healthy foods for each participant.
n
n
n
n
n
You have questions about your next appointment.
You have questions about nutrition or breastfeeding.
Your vouchers are lost or stolen.
Your name, address or phone number changes.
You have comments or concerns. Your feedback is important to us.
NAME OF LOCAL WIC AGENCY
WIC LOCAL AGENCY PHONE NUMBER
KEEP APPOINTMENTS
nPlease call your WIC Clinic
if you need to reschedule.
COMMON COURTESY
n Treat WIC and store staff
with respect and courtesy.
EQUAL TREATMENT
We treat you the same no matter
your race, color, age, national
origin, disability, or sex.
FAIRNESS
You may ask for a hearing if you do
not agree with WIC staff about your
eligibility for WIC.
Bring your WIC ID Folder every time
you go to the WIC Clinic or grocery store.
USE WIC VOUCHERS CORRECTLY
n Get vouchers from only one
WIC Clinic at a time.
n Shop at WIC-approved stores
in Minnesota only.
n Buy only the foods listed on the
voucher and Shopping Guide.
n Use vouchers on or between the
dates listed on each voucher.
nSort WIC foods by voucher. Separate
WIC foods from non-WIC items
when checking out at the store.
Keep this
WIC ID Folder
Always
bring this
WIC ID Folder
with you…
To your
WIC appointments
(along with your picture ID).
n
n
To the grocery store.
n
If you move.* (See back of brochure.)
HOUSEHOLD ID#
Moving to Another State*
n
n
n
PEOPLE AUTHORIZED TO PICK UP AND USE WIC VOUCHERS:
Please make sure everyone listed knows the WIC program rules.
Your WIC benefits will continue there!
Tell us. We’ll give you a transfer notice to take with you before you leave.
If you don’t have the notice before leaving, just take your WIC ID
folder to the new WIC agency. They can call us.
PARTICIPANT/PARENT/GUARDIAN
SIGNATURE
NAME
Questions about WIC Foods
REPORT WIC FRAUD OR ABUSE
nIf you know of any store or person
who is buying, selling or otherwise
misusing WIC foods or benefits,
please contact us by email at
[email protected] or
by phone at 1-800-657-3942.
NAME
SIGNATURE
If you have questions about WIC foods or trouble finding
WIC foods, call the state WIC office at 1-800-657-3942.
NAME
You can also visit the Minnesota Department of Health Website
at www.health.state.mn.us/wic
SIGNATURE
2017-2018 09/16 ID 53885
Delivery Date:_______ /_______ /_______
_______ /_______ /_______
Due Date:
_______ /_______ /_______
DOB:
Delivery Date:_______ /_______ /_______
_______ /_______ /_______
Due Date:
_______ /_______ /_______
DOB:
Delivery Date:_______ /_______ /_______
_______ /_______ /_______
Due Date:
_______ /_______ /_______
DOB:
Delivery Date:_______ /_______ /_______
_______ /_______ /_______
Due Date:
_______ /_______ /_______
DOB:
Delivery Date:_______ /_______ /_______
_______ /_______ /_______
Due Date:
_______ /_______ /_______
DOB:
Delivery Date:_______ /_______ /_______
of participant(s)
Name
_______ /_______ /_______
Due Date:
_______ /_______ /_______
DOB:
or Deliverydate
WICID#
DOB,DueDate
State
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
begin date
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
date mid-cert completed
CertificationPeriod
end date
Information
Additional
Interpreter needed/language:
Clinic
Clinic ID#
Agency ID#
WIC ID Folder
KEEP WIC VOUCHERS SAFE
n Handle WIC vouchers carefully.
n Report lost or stolen vouchers
immediately.
n Lost or stolen vouchers
might not be replaced.
n Never use WIC vouchers
reported lost or stolen.
Last date of income determination (migrant only)
/
/
What you
can expect
BREASTFEEDING SUPPORT
& NUTRITION EDUCATION
To help you feed your family
in a healthy way.
INFORMATION
About health care, immunizations,
and other programs.
WIC FOODS
Healthy foods for each participant.
What WIC
expects of you
HONESTY
n Do not break WIC rules. This can
result in you being taken off the
WIC program, having to pay back
money and/or facing legal charges.
n Do not hide facts or provide
false information to WIC.
n Never return WIC foods
for cash or credit.
n Never accept cash or credit
for WIC vouchers.
Never sell or trade your
WIC vouchers or WIC food.
n
Call Your
WIC Clinic if...
n
n
n
n
n
You have questions about your next appointment.
You have questions about nutrition or breastfeeding.
Your vouchers are lost or stolen.
Your name, address or phone number changes.
You have comments or concerns. Your feedback is important to us.
NAME OF LOCAL WIC AGENCY
WIC LOCAL AGENCY PHONE NUMBER
KEEP APPOINTMENTS
Please call your WIC Clinic
if you need to reschedule.
n
COMMON COURTESY
Treat WIC and store staff
with respect and courtesy.
n
EQUAL TREATMENT
We treat you the same no matter
your race, color, age, national
origin, disability, or sex.
FAIRNESS
You may ask for a hearing if you do
not agree with WIC staff about your
eligibility for WIC.
Keep this
WIC ID
Folder
Always
bring this
WIC ID Folder
with you…
If you move.* (See back of brochure.)
n
To the grocery store.
n
To your
WIC appointments
(along with your picture ID).
n
WIC ID Folder
KEEP WIC VOUCHERS SAFE
n Handle WIC vouchers carefully.
n Report lost or stolen vouchers
immediately.
n Lost or stolen vouchers
might not be replaced.
n Never use WIC vouchers
reported lost or stolen.
USE WIC VOUCHERS CORRECTLY
n Get vouchers from only one
WIC Clinic at a time.
n Shop at WIC-approved stores
in Minnesota only.
n Buy only the foods listed on the
voucher and Shopping Guide.
n Use vouchers on or between the
dates listed on each voucher.
n Sort WIC foods by voucher. Separate
WIC foods from non-WIC items
when checking out at the store.
REPORT WIC FRAUD OR ABUSE
n If you know of any store or person
who is buying, selling or otherwise
misusing WIC foods or benefits,
please contact us by email at
[email protected] or
by phone at 1-800-657-3942.
Bring your WIC ID Folder every time
you go to the WIC Clinic or grocery store.
Moving to Another State*
n
n
n
Your WIC benefits will continue there!
Tell us. We’ll give you a transfer notice to take with you before you leave.
If you don’t have the notice before leaving, just take your WIC ID
folder to the new WIC agency. They can call us.
Questions about WIC Foods
IfyouhavequestionsaboutWICfoods or trouble finding
WIC foods, call the state WIC office at 1-800-657-3942.
You can also visit the Minnesota Department of Health Website
at www.health.state.mn.us/wic
HOUSEHOLD ID#
PEOPLE AUTHORIZED TO PICK UP AND USE WIC VOUCHERS:
Please make sure everyone listed knows the WIC program rules.
NAME
PA R TIC IPA N T/ PA R EN T/ GUA R DIA N
SIGNATURE
NAME
SIGNATURE
NAME
SIGNATURE
2017-2018 09/16 ID 53885
Delivery Date:_______ /_______ /_______
DOB:
_______ /_______ /_______
Due Date:
_______ /_______ /_______
Delivery Date:_______ /_______ /_______
DOB:
_______ /_______ /_______
Due Date:
_______ /_______ /_______
Delivery Date:_______ /_______ /_______
DOB:
_______ /_______ /_______
Due Date:
_______ /_______ /_______
Delivery Date:_______ /_______ /_______
DOB:
_______ /_______ /_______
Due Date:
_______ /_______ /_______
Delivery Date:_______ /_______ /_______
DOB:
_______ /_______ /_______
Due Date:
_______ /_______ /_______
Delivery Date:_______ /_______ /_______
of participant(s)
Name
DOB:
_______ /_______ /_______
Due Date:
_______ /_______ /_______
DOB, Due Date
or Delivery date
WIC ID #
State
______ /_______ /______
______ /_______ /______
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______ /_______ /______
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______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
______ /_______ /______
begin date
date mid-cert completed
Certification Period
end date
Information
Additional
Interpreter needed/language:
Clinic
Clinic ID#
Agency ID#
Last date of income determination (migrant only)
/
/
Your WIC Appointments
Always keep your vouchers safe.
Your next nutrition appointment is circled below. Please call your WIC Clinic (phone number on back panel) as soon as possible if you cannot keep your next appointment.
2017
2018
WICSTAFF:Pleasemarkwitha“V”eachmonthvouchersareissued.
January
S
1
8
15
22
29
NEW
YEAR’S
DAY
M
2
9
MARTIN
LUTHER
16
KING
23
30
March
February
TIME
NAME(S)
TIME
NAME(S)
T
3
10
17
24
31
W
4
11
18
25
T
5
12
19
26
F
6
13
20
27
S
7
14
21
28
Picture ID
Child
January
TIME
NAME(S)
M
T
W
1
5 6 7 8
12 13 14 15
19 PRESIDENTS’
20
21 22
DAY
26 27 28
T F S
2 3 4
9 10 11
16 17 18
23 24 25
BRING IF CIRCLED:
BRING IF CIRCLED:
ID Folder
S
WICSTAFF:Pleasemarkwitha“V”eachmonthvouchersareissued.
ID Folder
S
TIME
NAME(S)
M
T
W
1
5 6 7 8
12 13 14 15
19 20 21 22
26 27 28 29
T
2
9
16
23
30
F
3
10
17
24
31
S
4
11
18
25
Child
ID Folder
7
14
21
28
M
1
8
MARTIN
LUTHER
15
KING
22
29
NEW
YEAR’S
DAY
TIME
NAME(S)
T
2
9
16
23
30
W
3
10
17
24
31
T F S
4 5 6
11 12 13
18 19 20
25 26 27
Picture ID
Child
ID Folder
S
TIME
NAME(S)
M
T
W
T F S
1 2 3
4 5 6 7 8 9 10
11 12 13 14 15 16 17
18 PRESIDENTS’
19
20 21 22 23 24
DAY
25 26 27 28
BRING IF CIRCLED:
BRING IF CIRCLED:
BRING IF CIRCLED:
Picture ID
S
March
February
Picture ID
Child
ID Folder
S
M
T
W
4
11
18
25
5 6 7
12 13 14
19 20 21
26 27 28
T F S
1 2 3
8 9 10
15 16 17
22 23 24
29 30 31
BRING IF CIRCLED:
Picture ID
Child
ID Folder
Picture ID
Child
PROOF OF:
PROOF OF:
PROOF OF:
PROOF OF:
PROOF OF:
PROOF OF:
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
April
May
June
April
May
June
TIME
NAME(S)
TIME
NAME(S)
S
M
T
W
T
F
2
9
16
23
30
3 4 5 6 7
10 11 12 13 14
17 18 19 20 21
24 25 26 27 28
S
1
8
15
22
29
BRING IF CIRCLED:
ID Folder
S
TIME
NAME(S)
M
1
7 8
14 15
21 22
28 MEMORIAL
29
DAY
T
2
9
16
23
30
W
3
10
17
24
31
T F S
4 5 6
11 12 13
18 19 20
25 26 27
BRING IF CIRCLED:
Picture ID
Child
ID Folder
TIME
NAME(S)
S
M
T
W
4
11
18
25
5 6 7
12 13 14
19 20 21
26 27 28
T F S
1 2 3
8 9 10
15 16 17
22 23 24
29 30
BRING IF CIRCLED:
Picture ID
Child
ID Folder
S
1
8
15
22
29
TIME
NAME(S)
M T W T
2 3 4 5
9 10 11 12
16 17 18 19
23 24 25 26
30
F
6
13
20
27
S
7
14
21
28
BRING IF CIRCLED:
Picture ID
Child
ID Folder
S
TIME
NAME(S)
M
T
1
6 7 8
13 14 15
20 21 22
27 MEMORIAL
28
29
DAY
W
2
9
16
23
30
T F S
3 4 5
10 11 12
17 18 19
24 25 26
31
BRING IF CIRCLED:
Picture ID
Child
ID Folder
S
M
T
W
T
F
1
3 4 5 6 7 8
10 11 12 13 14 15
17 18 19 20 21 22
24 25 26 27 28 29
S
2
9
16
23
30
BRING IF CIRCLED:
Picture ID
Child
ID Folder
Picture ID
Child
PROOF OF:
PROOF OF:
PROOF OF:
PROOF OF:
PROOF OF:
PROOF OF:
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
July
August
September
July
August
September
TIME
NAME(S)
TIME
NAME(S)
S
M
T
W
2
9
16
23
30
3 INDEPENDENCE
4 5
DAY
10 11 12
17 18 19
24 25 26
31
T
F
6 7
13 14
20 21
27 28
S
1
8
15
22
29
BRING IF CIRCLED:
ID Folder
S
TIME
NAME(S)
M
T
1
6 7 8
13 14 15
20 21 22
27 28 29
W
2
9
16
23
30
T F S
3 4 5
10 11 12
17 18 19
24 25 26
31
BRING IF CIRCLED:
Picture ID
Child
ID Folder
Picture ID
S
TIME
NAME(S)
M
T
W
T
F
1
3 LABOR
4 5 6 7 8
DAY
10 11 12 13 14 15
17 18 19 20 21 22
24 25 26 27 28 29
S
2
9
16
23
30
ID Folder
M
2
9
16
23
30
T W T F S
3 INDEPENDENCE
4 5 6 7
DAY
10 11 12 13 14
17 18 19 20 21
24 25 26 27 28
31
BRING IF CIRCLED:
BRING IF CIRCLED:
Child
S
1
8
15
22
29
TIME
NAME(S)
Picture ID
Child
ID Folder
S
TIME
NAME(S)
M
T
W
1
5 6 7 8
12 13 14 15
19 20 21 22
26 27 28 29
T
2
9
16
23
30
F
3
10
17
24
31
S
4
11
18
25
BRING IF CIRCLED:
Picture ID
Child
ID Folder
Picture ID
S
M
2
9
16
23
30
LABOR
DAY
T
W
T
F
3 4 5 6 7
10 11 12 13 14
17 18 19 20 21
24 25 26 27 28
S
1
8
15
22
29
BRING IF CIRCLED:
Child
ID Folder
Picture ID
Child
PROOF OF:
PROOF OF:
PROOF OF:
PROOF OF:
PROOF OF:
PROOF OF:
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
October
November
December
October
November
December
TIME
NAME(S)
S
1
8
15
22
29
M
2
9
16
23
30
TIME
NAME(S)
T
3
10
17
24
31
W
4
11
18
25
T F S
5 6 7
12 13 14
19 20 21
26 27 28
BRING IF CIRCLED:
ID Folder
Picture ID
S
M
TIME
NAME(S)
T
W T F S
1 2 3 4
VETERANS’
DAY
5 6 7 8 9 10
(OBS.) 11
12 13 14 15 16 17 18
19 20 21 22THANKSGIVING
23
24 25
DAY
26 27 28 29 30
BRING IF CIRCLED:
Child
ID Folder
Picture ID
S
3
10
17
24
31
M
TIME
NAME(S)
T
W
T
F
1
4 5 6 7 8
11 12 13 14 15
18 19 20 21 22
CHRISTMAS
25
26 27 28 29
DAY
S
2
9
16
23
30
BRING IF CIRCLED:
Child
ID Folder
Picture ID
S
7
14
21
28
TIME
NAME(S)
M T W
1 2 3
8 9 10
15 16 17
22 23 24
29 30 31
T F S
4 5 6
11 12 13
18 19 20
25 26 27
BRING IF CIRCLED:
Child
ID Folder
Picture ID
S
M
TIME
NAME(S)
T
W
T F
1 2
4 5 6 7 8 9
11 VETERANS’
12
13 14 15 16
DAY
(OBS.)
18 19 20 21 THANKSGIVING
22
DAY 23
25 26 27 28 29 30
S
3
10
17
24
BRING IF CIRCLED:
Child
ID Folder
Picture ID
S
M
T
W
T
F
2
9
16
23
30
3 4 5 6 7
10 11 12 13 14
17 18 19 20 21
24 CHRISTMAS
25
26 27 28
DAY
31
S
1
8
15
22
29
BRING IF CIRCLED:
Child
ID Folder
Picture ID
Child
PROOF OF:
PROOF OF:
PROOF OF:
PROOF OF:
PROOF OF:
PROOF OF:
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
Address Income MA/MFIP MnCare
Other _________________________________________
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: Mail:
U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; Fax: (202) 690-7442;
or Email: [email protected]. This institution is an equal opportunity provider.