Page 632

USDA Nondiscrimination Statement

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of 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.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain 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 have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (866) 632- 9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to:

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. email: FNSCIVILRIGHTSCOMPLAINTS@usda.gov

This institution is an equal opportunity provider.

DOMESTIC VIOLENCE INFORMATION Domestic violence information and services are available to anyone experiencing violence or abuse from their partner. If you are in immediate danger, call 911. If you would like to speak with, text or chat with someone who understands these issues or to learn about services and safety options, contact the Virginia Statewide Hotline. • Call and speak with an advocate toll-free at 1-800-838-8238. (Note: Interpreters are available for more than 200 languages via the Language Line.) • Text with an advocate at 804-793-9999. • Chat with an advocate at https://www.vadata.org/chat/. (Chat feature works best on a computer or tablet.) • Call and speak with an advocate - LGBTQ Helpline: 1-866-356-6998

Commonwealth of Virginia Voter Registration Agency Certification If you are not registered to vote where you live now, would you like to apply to register to vote here today? (Please check only one)

 I am already registered to vote at my current address, or I am not eligible to register to vote and do not need an application to register to vote.  Yes, I would like to apply to register to vote. (Please fill out the voter registration application form)  No, I do not want to register to vote.

If you do not check any box, you will be considered to have decided not to register to vote at this time. Applying to register to vote or declining to register to vote will not affect the assistance or services that you will be provided by this agency. If you decline to register to vote, this fact will remain confidential. If you do register to vote, the office where your application was submitted will be kept confidential, and it will be used only for voter registration purposes. If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private if you desire.

If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, you may file a complaint with: Secretary of the Virginia State Board of Elections, Washington Building, 1100 Bank Street, Richmond, VA 23219-3497, telephone (804) 864-8901.

______________________________________ ______________________________________ _______________________ Applicant Name Signature Date

for agency use only Voter Registration form completed:  Yes  No Voter Registration form given to applicant for later mailing (at applicant’s request) 

____________________________________________________ ________________________________________________ Agency Staff Signature

Date ii