Free WIC Civil Rights Discrimination Complaint, DPH 40082 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 40082 (08/06)

STATE OF WISCONSIN

Project Name Project Phone Mailing Address City, State, Zip

WIC PROGRAM CIVIL RIGHTS DISCRIMINATION COMPLAINT FORM
This form may be used for WIC Farmers' Market Nutrition Program (FMNP) purposes. Participation in WIC is voluntary. Personally identifiable information is used to determine WIC eligibility and may be disclosed to others only as allowed by state and federal laws.

Guardian's Name Address City, State, Zip In accordance with Federal law and U.S. Department of Agriculture policy, WIC is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. If you think you have been discriminated against, please complete this form and send it to: Regional Director Civil Rights/EEO USDA, FNS, MWRO 77 W Jackson Blvd., 20thFloor Chicago, IL 60604-3591 USDA, Director Office of Civil Rights 1400 Independence Ave, SW Washington, D.C. 20250-9410 or call (800) 795-3272 or (202) 720-6382 (TTY)

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USDA is an Equal Opportunity Provider and Employer Your name: Your address: Telephone number where you can be contacted: E-mail address (if available): Name and title of person you believe discriminated against you:
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Address: Date of discrimination: _________________________________ Check the type of discrimination: race ___ color ___ national origin ___ sex ___ age ___ disability ___ Please describe what happened: _____________________________________________________________________________
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Name and address of any witnesses:

Your signature: __________________________________ Date: