| REQUEST FOR COMPLIANCE |
Office of Administrative Hearings
P.O. BOX 1930
Albany, NY 12201-1930
Fax:(518) 473-6735 |
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| Note: For security
purposes, you have 15 minutes to complete this form, otherwise your request will
not be received and you will need to start over.
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Indicates Required Information. Correct and complete information will permit us to promptly process your request.
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| Personal Information |
| (If fair hearing is for someone other than the case name, describe who it is for in the comments box below.) |
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| Case Information |
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| Representative/Requestor Information |
| (If there is a representative or you are NOT the person listed above.) |
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I do not feel the local social services agency has complied with my decision because:
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| (Please be specific and brief, including dollar amounts and dates when possible.) |
You have 500 characters remaining for your description...
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Enter the name of person filling out this form
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If your issue involves SNAP, the following policy applies as means of seeking to have any concerns you may have that decisions may have been inappropriately made based on the protected bases noted.
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, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs).
Remedies and complaint filing deadlines vary by program or incident.
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 responsible Agency or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or 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 discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint 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.
USDA is an equal opportunity provider, employer, and lender.
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