Hinton Comm School District

AD-3027 OMB Control No: 0508-0002 · Expiration Date: 09/30/2027 · U.S. Department of Agriculture · Complainant Information · First name Middle Initial Last Name · Mailing Address (Include Full City · State and Zip Code) · Primary Phone Number Alternate Phone Number Email · Best way to reach you: ☐ Mail ☐ Phone ☐ Email ☐ Other · If you have difficulty understanding the English language · you may request language assistance services by calling · 866-632-9992. Assistance will be available for individuals who are not proficient in English. Persons with disabilities who · require alternative means of communication (e.g. · braille · large print · American Sign Language) should contact the · responsible State or local Agency that administers the program or contact the United States Department of Agriculture · (USDA) through the Federal Telecommunications Relay Service at 711 (voice TTY). · Representative Information · Do you have a representative? ☐ Yes ☐ No Do you have written authorization from representative? · If so · please attach. ☐ Yes ☐ No · First name Last Name · Mailing address (Include Full City · State and Zip Code) · Phone Email · Complaint Information · (attach additional pages and supporting documentation as needed) · 1. Provide the name of the program you applied for (if known/applicable). · 2. Select the USDA agency that conducts the program or provides Federal financial assistance for the program.