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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