California Department of Social Services
Child and Adult Care Food Program Branch
Child and Adult Care Food Program
CACFP 29 (Rev. 05/2023)
U.S. Department of Agriculture (USDA) Nondiscrimination Statement
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights
regulations and policies, this institution is prohibited from discriminating on the basis of race, color,
national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or
retaliation for prior civil rights activity.
Program information may be made available in languages other than English. Persons with
disabilities who require alternative means of communication to obtain program information (e.g.,
Braille, large print, audiotape, American Sign Language), should contact the responsible state or
local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and
TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.
To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA
Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/
sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (866) 632-9992, or by
writing a letter addressed to USDA. The letter must contain the complainant’s name, address,
telephone number, and a written description of the alleged discriminatory action in sufficient detail to
inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil
rights violation. The completed AD-3027 form or letter must be submitted 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; or
2. Fax: (833) 256-1665 or 202-690-7442; or
3. Email: program.intake@usda.gov
This institution is an equal opportunity provider.