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 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, a refusal to hold a religious belief, or a 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 USDA direct assistance;

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

•  You may report violations of these protections (including denials of services or benefits) to _____.

We must provide you with this written notice before you enroll in our program or receive services from the program, as required by 7 CFR part 16.

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. Your use of this form is voluntary.

If you object to the religious character of our organization, we must make reasonable efforts to identify and refer you to an alternate provider to which you have no objection. We cannot guarantee, however, that in every instance, an alternate provider will be available. With your consent, we will follow up with you or the organization to which you are referred to determine whether you have contacted that organization.

(  )  Please check if you want to be referred to another service provider.

Please provide the following information if you want us to follow up with you:

Your Name:

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

Please provide the following information if you want us to follow up with the service provider only.

Your Name:

You are permitted to withhold your name, though if you choose to do so, we will be unable to follow up with you or the service provider about your referral.

(  )  Please check if you do not want follow up.

FOR STAFF USE ONLY

1. Date of Objection: _/_/_

2. Referral (check one):

(  )  Individual was referred to (name of alternate provider and contact information):

(  )  Individual left without a referral

(  )  No alternate service provider is available—summarize below what efforts you made to identify an alternate provider (including reaching out to USDA or the intermediary, if applicable):

3. Follow-up date: _/_/_

(   ) Individual contacted alternate provider

(   ) Individual did not contact alternate provider

4. Staff name and initials:

—End of Form—

[81 FR 19415, Apr. 4, 2016]