Do you have a disability and need a reasonable modification or communication assistance to access DFCS services?

To request a reasonable modification, communication assistance, or extra help, please complete the form below. You are not required to complete this form or tell us your disability in order to receive reasonable modifications, communication assistance, or extra help.

Persons with Disabilities Information
Name
Name of the person with a disability who needs a reasonable modification, communication assistance, or extra help.
Address of person with disability
Please check the DFCS program(s) that apply
Medicaid and PeachCare for Kids®
Do you need a reasonable modification because of a disability?
Do you or your companion need communication assistance because of a disability? If yes, please tell us so that we can assist you. (Select all that apply)
Do you need this reasonable modificaton, communication assistance, or extra help:
Requester's information
Requester's name
Nondiscrimination Statement
Nondiscrimination Statement

This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some cases religion or political beliefs.

The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin, sex, 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.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), 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.  Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, 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: U.S. Department of Agriculture
             Office of the Assistant Secretary for Civil Rights
             1400 Independence Avenue, SW 
             Washington, D.C. 20250-9410

(2)     fax: (202) 690-7442; or 

(3)     email: program.intake@usda.gov.

For any other information dealing with Supplemental Nutrition Assistance Program (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: http://www.fns.usda.gov/snap/contact_info/hotlines.htm.

To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (800) 368-1019 (voice) or (800) 537-7697 (TTY). 

This institution is an equal opportunity provider.