Complaint Form

Complaint Form

Please fill in the form below. *Required Fields
If you feel you have not been treated well or were denied services, you should first try to talk with your case manager to resolve the issue. If you have not been able to resolve the concern with your case manager or you do not feel comfortable talking to your case manager, you can request to talk to a manager or you can complete this form. A manager will respond to you within one business day.

You may also contact the FSET Regional Manager, Thomas Prete directly at (715) 421 – 8608 or via email at prete@changewithin.net.

If you want to file a Fair Hearing, that is a separate process from a complaint. You can ask any FSET worker to file a fair hearing on your behalf. You can also file a hearing request by calling the Division of Hearing and Appeals at (608) 266-3096 or mailing a written request to:

Department of Administration Division of Hearing and Appeals

P.O. Box 7875 Madison, WI 53707-7875
PIN Number
If you don't know it, that's okay!
Name*

First NameLast Name
Address*

Street Address

City

StateCounty

Zip Code
Phone Number*

Area CodePhone Number
E-mail
Birthday*

MonthDayYear
Who is your case manager or worker?
Please explain your concern*
Have you talked with your case manager about this issue?

YesNo
How would you like your concern resolved?*
Non-Discrimination Statement

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. 20250-9410;

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

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

This institution is an equal opportunity provider
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