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Full Name: Phone:
Address: City:
State: Zip:
Business Name:    
Are you a woman?      
Did you farm at any time between 1981 and 2011?
Did you own, lease or plan to own or lease farm land?
Did you apply for loan(s) or loan servicing at a USDA office between 1981 and 2011?
Were the loan(s) or loan servicing you applied for:

Did the USDA's treatment of you lead to financial harm?
Did you complain of discrimination between 1981 and 2011 to USDA or a representative who complained to USDA on your behalf regarding USDA's treatment of you?
Do you already have a lawyer to represent you in a Discrimination case against USDA?  
Are you acting on behalf of someone deceased?