• FOOD DISTRIBUTION PROGRAM PERSONAL WAGE RECORD

  • P.O. Box 59

    Watonga, OK 73772

    (405)276-6049

    Toll Free: (888)747-9520

    Fax: (405)422-8261

    Please keep a record of your employment and/or income from what you sell. Give this form to the program clerk at your next appointment. You may ask the person from whom you work or to whom you sell to fill in the information for you. Please list working phone numbers.

  • FILL IN AS MUCH INFORMATION AS POSSIBLE

  •  

    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 , 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. 20250-941 O;

    (2)                   fax: (202) 690-7442; or

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

    This institution is an equal opportunity provider.

  • Should be Empty: