The purpose of this form is to assist you in filing an MDA program discrimination complaint. For help filling out the form, you may call 651-201-6657 or 800-967-2474 or 711 TTY. You are not required to use the complaint form. You may write a letter instead. If you write a letter it must contain all of the information requested in this form and be signed by you or your authorized representative. Incomplete information will delay the processing of your complaint.
You may also send a complaint by FAX 651-201-6118 or e-mail firstname.lastname@example.org. We must have a signed copy of your complaint, so if you send your complaint by e-mail, be sure to attach the signed copy to your email. Incomplete information or an unsigned form will delay the processing of your complaint.
Mail completed form to:
Minnesota Department of Agriculture
625 Robert Street North
Saint Paul, MN 55155
A program discrimination complaint must be filed not later than 180 days of the date you knew or should have known of the alleged discrimination, unless the time for filing is extended by MDA. Complaints sent by mail are considered filed on the date the complaint was signed, unless the date on the complaint letter differs by seven days or more from the postmark date, in which case the postmark date will be used as the filing date. Complaints sent by fax or email will be considered filed on the day the complaint is faxed or emailed. Complaints filed after the 180-day deadline must include a ‘good cause’ explanation for the delay. For example, you may have “good cause” if:
- You could not reasonably have been expected to know of the discriminatory act within the 180-day period;
- You were seriously ill or incapacitated;
- The same complaint was filed with another Federal, state, or local agency and that agency failed to act on your complaint.
Federal law and policy prohibits discrimination against you based on the following: race, color, national origin, religion, sex, disability, age, marital status, sexual orientation, family/parental status, public assistance program, and political beliefs. (Not all bases apply to all programs). MDA will determine if it has jurisdiction under the law to process the complaint on the bases identified and in the programs involved. Reprisal that is based on prior civil rights activity is prohibited.
If this complaint involves a farm or other real estate property that is not your current address, write in the address for that farm or real estate property. Otherwise, this part of the form can be left blank.
Important Legal Information
This MDA Program Discrimination Complaint Form is provided in accordance with the Privacy Act of 1974, 5 U.S.C. §552a, and concerns the information requested in this form to which this Notice is attached. The MDA requests this information pursuant to 7 CFR Part 15. If the completed form is accepted as a complaint case, the information collected during the investigation will be used to process your program discrimination complaint. Disclosure is voluntary. However, failure to supply the requested information or to sign the form may result in dismissal of your complaint. If your complaint is dismissed you will be notified. The information you provide in this complaint may be disclosed to outside parties where MDA determines that disclosure is: 1) Relevant and necessary to the Department of Justice, the court or other tribunal, or the other party before such tribunal for purposes of litigation; 2) Necessary for enforcement proceedings against a program that MDA finds to have violated laws or regulations; 3) In response to a Congressional office if you have requested that the Congressional office inquire about your complaint or; 4) To the United States Civil Rights Commission in response to its request for information.
Reprisal (Retaliation) Prohibited
No Agency, officer, employee, or agent of the MDA, including persons representing the MDA and its programs, shall intimidate, threaten, harass, coerce, discriminate against, or otherwise retaliate against anyone who has filed a complaint of alleged discrimination or who participates in
any manner in an investigation or other proceeding raising claims of discrimination.
Privacy Notice / Tennessen Warning:
MDA is requesting you complete this form so that MDA staff can assess your claim of discrimination. Upon the form’s submission, MDA staff will use the information you provide as the basis of an investigation. You are not legally required to provide MDA with the data requested on this form; you may refuse to do so. However, failure to complete this form in its entirety may make it more difficult for MDA to accurately assess the circumstances that led to your complaint, and may impact the investigation’s conclusions. Some of the data being requested on this form will be classified as private data under Minnesota law. Parties that may gain access to private data include MDA staff and contractors with a valid work assignment to access the data, parties authorized by you or by a valid court order, Minnesota Management and Budget, Minnesota Department of Administration, the state auditor, the legislative auditor, and any other person or entity authorized by state law, federal law, federal regulation, or federal subpoena to receive the data. If necessary, MDA may also share the data with law enforcement and the Minnesota Office of the Attorney General.