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NONDISCRIMINATION STATEMENT In accordance with federal civil rights laws 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 (including gender identity and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Programs that receive federal financial assistance from the U.S. Department of Health and Human Services (HHS), such as Temporary Assistance for Needy Families (TANF), and programs HHS directly operates are also prohibited from discrimination under federal civil rights laws and HHS regulations.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or who 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.

CIVIL RIGHTS COMPLAINTS INVOLVING USDA PROGRAMS USDA provides federal financial assistance for many food security and hunger reduction programs such as the Supplemental Nutrition Assistance Program (SNAP), the Food Distribution Program on Indian Reservations (FDPIR) and others. To file a program complaint of discrimination, complete the Program Discrimination Complaint Form, (AD-3027) found online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, 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: Food and Nutrition Service, USDA,1320 Braddock Place, Room 334, Alexandria, VA 22314; or 2. fax: (833) 256-1665 or (202) 690-7442; or 3. phone: (833) 620-1071; or 4. email: FNSCIVILRIGHTSCOMPLAINTS@usda.gov.

For any other information regarding SNAP issues, persons should either contact the USDA SNAP hotline number at (800) 221-5689, which is also in Spanish, or call the state information/hotline numbers (click the link for a listing of hotline numbers by state); found online at: SNAP hotline.

CIVIL RIGHTS COMPLAINTS INVOLVING HHS PROGRAMS HHS provides federal financial assistance for many programs to enhance health and well-being, including TANF, Head Start, the Low- Income Home Energy Assistance Program (LIHEAP), and others. If you believe that you have been discriminated against because of your race, color, national origin, disability, age, sex (including pregnancy, sexual orientation, and gender identity), or religion in programs or activities that HHS directly operates or to which HHS provides federal financial assistance, you may file a complaint with the Office for Civil Rights (OCR) for yourself or for someone else.

To file a complaint of discrimination for yourself or someone else regarding a program receiving federal financial assistance through HHS, complete the form online through OCR’s Complaint Portal at https://ocrportal.hhs.gov/ocr/. You may also contact OCR via

1. mail: Centralized Case Management Operations, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201; or 2. fax: (202) 619-3818; or 3. email: OCRmail@hhs.gov.

For faster processing, we encourage you to use the OCR online portal to file complaints rather than filing via mail. Persons who need assistance with filing a civil rights complaint can email OCR at OCRMail@hhs.gov or call OCR toll-free at 1-800-368-1019, TDD 1-800- 537-7697. For persons who are deaf, hard of hearing, or have speech difficulties, please dial 7-1-1 to access telecommunications relay services. We also provide alternative formats (such as Braille and large print), auxiliary aids and language assistance services free of charge for filing a complaint.

This institution is an equal opportunity provider.

1. Do not write in shaded areas. These areas are for agency use only.

2. Complete SECTION A: APPLICANT INFORMATION. Complete the grid in SECTION B: Household Composition for everyone who lives in your home, even if you are not applying for that person. You may leave questions about citizenship, immigration and Social Security Number blank for anyone for whom you are NOT requesting assistance.

3. Answer the questions in SECTION C: INCOME for everyone for whom you are applying. In addition, if you are applying for TANF, also provide income information for children age 18 or under, even if you are not applying for that child, and for the stepparent of the children for whom you are applying.

4. Answer the questions in SECTION D: RESOURCES for everyone for whom you are applying unless you are applying only for TANF.

5. After completing Sections A through D, answer the questions in the sections indicated below, depending on the type of assistance you are requesting.

TANF Section E, page 5 TANF Diversionary/Emergency Assistance Section F, page 6 SNAP Section G, page 6 Auxiliary Grants Section H, pages 7-8

6. Complete SECTION I for all programs if you want to have an Authorized Representative act on your behalf.

7. Read CHANGE REPORTING AND PENALTIES on pages 9-10.

8. Read and complete the last page of this application. Be sure to sign and date the application on Page 11. ii INSTRUCTIONS FOR COMPLETING THE APPLICATION