Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-80983 (04/09)

STATE OF WISCONSIN AD 19.1, 31.8, 60.3, 52.3, 36.4;32.6

CIVIL RIGHTS COMPLAINT
Any consumer of Department of Health Services (DHS) services and benefits funded by the U.S. Department of Health and Human Services (DHHS) may file a civil rights complaint at any time with the DHS Affirmative Action and Civil Rights Compliance (AA/CRC) Office. You may also file a discrimination complaint with the U.S. DHHS Office for Civil Rights, Region V. Any complaint about the

Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps, or known in Wisconsin as the FoodShare Program (FoodShare Wisconsin), WIC or The Emergency Food Assistance Program (TEFAP) must be filed with the
USDA. Complaints filed with the U.S. DHHS and USDA must be filed within 180 days of the alleged discriminatory act. SECTION I ­ COMPLAINANT Important! The complainant must notify the DHS AA/CRC Office if there is a change in address or telephone number. If the office is not able to locate the complainant, the complaint may be closed. First Name Address ­ Street Home Telephone Number Middle Initial City Work Telephone Number Last Name ZIP Code E-mail Address Filing Date County FAX

SECTION II ­ RESPONDENT / PROVIDER INFORMATION Name ­ Organization / Agency Name ­ Person Representing Respondent Address ­ Representative City

Type Org. County, City, State Organizational Title ZIP Code E-mail Address

For Profit Non-Profit

County

Telephone Number ­ Include Area Code and Extension

SECTION III ­ REASON FOR DISCRIMINATION Check only the boxes that are the reason for your complaint. If you checked a box with an asterisk (*), you must provide your protected status or preferred language here: * Color * Disability * Gender * Race / Ethnicity Other: Religion Political Affiliation Retaliation * Age (40 or over) ­ Birthdate: National Origin or Limited English Proficiency ­ Preferred Language:

SECTION IV ­ DISCRIMINATION STATEMENT Use additional pages, as is necessary, to fully complete this section. 1. Describe the events that led you to file this complaint. 2. Give the date each action occurred and name of the person who took the action. 3. Explain how each action was related to the box(es) you checked in Section III.

SECTION V ­ CERTIFICATION AND SIGNATURE By my signature below, I declare this complaint is true and correct to the best of my knowledge and belief.

SIGNATURE - Complainant

Date Signed

Mail To: DHS Affirmative Action & Civil Rights Compliance Office 1 W. Wilson, Box 7850 Madison, WI 53707-7850

Other Contact Information FAX : 608-267-2147 E-Mail: [email protected]

F-80983 (04/09) SECTION IV ­ DISCRIMINATION STATEMENT CONTINUATION

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F-80983 (04/09) SECTION IV ­ DISCRIMINATION STATEMENT CONTINUATION

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