NOTICE OF BENEFICIARY RIGHTS

Name of Organization:

Name of Program:

Contact Information for Program Staff (name, phone number, and email address, if appropriate):

Because this program is supported in whole or in part by direct financial assistance from the Federal Government, we are required to let you know that—

•  We may not discriminate against you on the basis of religion or religious belief, your refusal to hold a religious belief, or your refusal to attend or participate in a religious practice;

•  We may not require you to attend or participate in any explicitly religious activities that are offered by us, and any participation by you in these activities must be purely voluntary;

•  We must separate in time or location any privately funded explicitly religious activities from activities supported with direct Federal financial assistance under this program;

•  If you object to the religious character of our organization, we must make reasonable efforts to identify and refer you to an alternative provider to which you have no objection; however, we cannot guarantee that in every instance, an alternative provider will be available; and

•  You may report violations of these protections, including any denials of services or benefits, by contacting or filing a written complaint with the Department of Homeland Security, Office for Civil Rights and Civil Liberties:

E-mail: CRCLCompliance@hq.dhs.gov.

Fax: 202-401-4708.

U.S. Mail: U.S. Department of Homeland Security Office for Civil Rights and Civil Liberties, Compliance Branch, 245 Murray Lane SW., Building 410, Mail Stop #0190, Washington, DC 20528.

{Where the program involves an intermediary, the recipient or intermediary should add where feasible:

You may also report violations of these protections, including any denials of services or benefits, to:

[Name and contact information for the intermediary]}

We must give you this written notice before you enroll in our program or receive services from the program.

BENEFICIARY REFERRAL REQUEST

If you object to receiving services from us based on the religious character of our organization, please complete this form and return it to the program contact identified above. If you object, we will make reasonable efforts to refer you to another service provider. With your consent, we will follow up with you or the organization to which you were referred to determine whether you contacted that organization.

Please check if applicable:

(  )  I want to be referred to another service provider.

If you checked above that you wish to be referred to another service provider, please check one of the following:

(  )  Please follow up with me.

Name:

Best way to reach me (phone/address/email):

(  )  Please follow up with the service provider to which I was referred.

(  )  Please do not follow up.

—End of Form—