- To provide the individual alleging a violation of civil rights with a means of signing a complaint form.
- To provide a means of assigning the investigation of a complaint to the civil rights office and recording information about the civil rights violation allegations.
When to Prepare
Persons wishing to complain of alleged civil rights violations complete Form H4870 to formalize their complaint. The staff person receiving the complaint assists the complainant in completing this form if necessary.
Number of Copies
Complete three copies of Form H4870.
Distribute copies as follows:
- Original to the civil rights office to whom complaint is referred.
- One copy to the complainant at the time he or she signs the form.
- One copy to the director of the Civil Rights Department, state office. This copy is held in suspense pending outcome of the regional decision.
If the complainant wants to file the complaint with USDA-FNS, send one additional copy to
Director, Civil Rights, USDA-FNS
1100 Commerce St.
Dallas, Texas 75242
The civil rights office handling the complaint and the Civil Rights Department keep copies for at least three years after the complaint process is completed.
The complainant or other person completes Form H4870 except the area identified at the bottom for HHSC use only.
Enter the name, telephone number, and address.
Enter the person's name, organization, and/or agency complaining against and the date the alleged incident occurred. Include the agency office address.
Mark the appropriate boxes identifying the charge of discrimination and the reason for the complaint.
Complete the area indicated for an explanation of the complaint in as much detail as possible. Include names, titles, and addresses of people who may have knowledge of the discriminatory acts. Include the date or dates on which the acts occurred.
The complainant signs and dates the form on the line indicated. Give the agency case number and social security number, if any.
If someone other than the client completes the form, the person enters his name, address, and telephone number.
FORM AREA FOR HHSC USE ONLY
The person who accepted the complaint signs, and enters his office address and the date received.
Enter the name of the regional or state office civil rights person the complaint form is routed to, and the date sent.