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Montana WIC Program General Complaint Form

Please complete this form and tap ‘Submit’ send it to the Montana WIC Program State Office. State staff will review and be in touch with follow-up instructions.

    Who is filing the complaint? *

    If "Other", please specify:

    Date of Incident:

    Location of incident:

    Your Name?:

    Your email: *

    Your Phone:

    Please describe in detail the incident that has occurred:

    Complaint Authorization

    USDA Nondiscrimination Statement

    In accordance with Federal civil rights law 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, disability, age, 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 availablein languages other than English.

    To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) 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: [email protected].

    This institution is an equal opportunity provider.

    JPMA, Inc.