Food & Nutrition Services Refund Request Form

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, 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. ascr.usda.gov/sites/default/files/USDA-OASCR%20P-Complaint- Form-0508-0002-508-11-28-17Fax2Mail.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:

mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410; or

fax:
(833) 256-1665 or (202) 690-7442; or

email:
Program.Intake@usda.gov

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Email *
Student Name & Student ID # (4300) *
Pay to (Parent/Guardian) (Must match what is on file) *
Mailing Address (Must match address on file) *
City, State & Zip Code *
Daytime Phone Number *
School Site *
Reason for Request *
Amount of Refund Requested (Please be sure that you remove any Credit Card attached to meal accounts that auto replenish when account are zeroed or have a low balance). *
Donate funds to the Lunch Fairy? (The Lunch Fairy Account is an emergency lunch account that funds Martin County School District students who are unable to pay for their school meals.  If you would like to support this program, you may donate balance from your child's  meal account ) *
A copy of your responses will be emailed to the address you provided.
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