Online Discrimination Complaint Form

This form is only for submitting Civil Rights complaints of discrimination.

If you feel that you have been discriminated against, you may complete the PA 607, Complaint of Discriminatory Treatment form at any DPSS public facing office or you may submit your complaint directly to the Civil Rights Section by completing the form fields on this page.

NOTE: This form is intended for DPSS Customers or their Authorized Representatives only.

Date of Occurrence:

Claimant Position DPSS Customer Authorized Representative

Case Name

DPSS Case Number

Address:

Telephone:

I believe I was retaliated against because:

Name(s) and Title(s) of the person(s) who I believe discriminated/retaliated against me:

Office Location

The action, decision, or condition which caused me to file this complaint is as follows:

I wish to have the following corrective action taken:

Consent CONSENT GRANTED - By selecting this option, I am authorizing the Department of Public Social Services, Civil Rights Section (CRS) to reveal my identity and other personal information to persons at the organization or institution under investigation and to other Federal and State agencies in accordance with applicable Federal and State laws and regulations. I hereby authorize CRS to receive material and information including, but not limited to applications, case files, personal records, and medical records. The material and information shall be used for authorized civil rights compliance and enforcement activities. I understand that I am not required to authorize this release and I do so voluntarily. CONSENT DENIED - I do not give my consent for the release of my name or other personally identifying information. I understand that this complaint may not be investigated as a result of my refusal to give my consent for the release of information.

USDA Non-Discrimination Statement