Sheet: Part I 

Sheet: Part II & III

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number for this information collection is 0572-0047.  The time required to complete this information collection is estimated to average 10 hours per response, including the time to review 

instructions, search existing data resources, gather the data needed, and complete and review the information.

BORROWER DESIGNATION

U.S. DEPARTMENT OF AGRICULTURE

Rural Utilities Service

NAME OF BORROWER

REPORT OF

COMPLIANCE AND PARTICIPATION

DATE

CALENDAR YEAR

must be answered.

PART I.  FOR ALL RUS ELECTRIC AND TELECOMMUNICATIONS BORROWERS

1.

Does your organization deny to any person on the basis of race, color, national origin, disability, or age, an equal opportunity for:

a.  Existing, improved or expanded service? .........................................................................................................

YES

NO

b.  Use of facilities? .........................................................................................................................................

YES

NO

c.  Access to facilities by disabled persons as required by Federal accessibility standards? ..........................................

YES

NO

2.

Does your organization post at a location easily viewed by the public:

a.  "AND JUSTICE FOR ALL" poster? .................................................................................................................

YES

NO

b.  Statement of Nondiscrimination? ...................................................................................................................

YES

NO

3.

a.  Title VI of the Civil Rights Act of 1964? ............................................................................................................

YES

NO

b.  Section 504 of the Rehabilitation Act of 1973 (disability)? ...................................................................................

YES

NO

c.  Age Discrimination Act of 1975 (age)? ............................................................................................................

YES

NO

4.

Does your organization provide information on the application of civil rights regulations to your program by:

a.  Publishing the Statement of Nondiscrimination in newspapers annually? ...............................................................

YES

NO

     (1)  customer? ...........................................................................................................................................

YES

NO

     (2)  employee, when hired? ..........................................................................................................................

YES

NO

5.

Does your organization:

a.  Provide an equal opportunity for minority and/or female-owned enterprises to participate in the bidding process for contracts?

YES

NO

b.  Develop and administer equitable line extension and/or security deposit policies for all customers? ............................

YES

NO

c.  Have an equitable disconnect policy? .............................................................................................................

YES

NO

6.

availability of payment options (budget billing, etc.)? ..............................................................................................

YES

NO

7.

Was a senior management official appointed to administer the requirements of the Civil Rights act of 1964, Section 504 of the

Rehabilitation Act of 1973, and the Age Discrimination act of 1975? ..........................................................................

YES

NO

Title:

8.

How does your organization collect and maintain racial/ethnic data on customers?

a.  Customer record coded at time of application for service (self identification or visual observation) ................................

YES

NO

b.  Pro-rated based on latest census data ............................................................................................................

YES

NO

9a.

for your service area or your own records):

  9b.  Total Number of Residential customers at End of 

% of Residential

         Calendar Year:

Customers

(must add to 100%)

  9c.  Total Number of Residential Disconnects For

(1)  American Indian or Alaska Native

(2)  Asian

         Non-Payment in Calendar Year:

(3)  Black or African American

(4)  Native Hawaiian or Other Pacific Islander

  9d.  Total Number of New Residential Customers

(5)  White

(6)  Hispanic or Latino

         Connected During Calendar Year:

(7)  Other

Total

0.0

  Comments:

PART II.  FORM COOPERATIVE-TYPE BORROWERS ONLY

10.

Does your organization deny to any person on the basis of race, color, national origin, disability, or age, and equal opportunity

to participate in the organization's activities and affairs? ................................................................................................

YES

NO

11.

Does your organization provide each new member with a copy of the bylaws? ..................................................................

YES

NO

12.

Does your organization provide all members with the bylaws section on the election process? ............................................

YES

NO

a.  Date/time of Annual Meeting:

b.  If no annual meeting, dates/times of nominating or district meetings:

c.  Does your organization provide all members advance notice of the annual meeting or election? .......................................

YES

NO

d.  Annual meeting is held at a facility accessible to persons with disabilities? .................................................................

YES

NO

13.

     Complete columns Only for Committees used by your cooperative.

MEMBER

ANNUAL MEETING

OTHER

RACIAL/ETHNIC

ADVISORY

PLANNING

ELECTION

COMMITTEE

TOTAL NUMBER

GROUP

COMMITTEE

COMMITTEE

COMMITTEE

(Except Nominating)

APPOINTED

(1)

(2)

(3)

(4)

(5)

MALE

FEMALE

MALE

FEMALE

MALE

FEMALE

MALE

FEMALE

MALE

FEMALE

a.

American Indian or Alaska Native

b.

Asian

c.

Black or African American

d.

Native Hawaiian or Other Pacific

Islander

e.

White

f.

Hispanic or Latino

g.

Other

TOTAL

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

14.

Did your organization promote minority and/or female representation on the board of directors during the Calendar Year to more

accurately reflect the composition of your membership:

a.  Appointing minority or female members to fill unexpired terms? ....................................................................

N/A

YES

NO

b.  Creating at-large positions on the board and initially filling positions with minority or female members? ...............................

YES

NO

c.  Appointing minority or female members to serve as special advisors to the board? .........................................................

YES

NO

15.

Did your organization have a quorum for the members' annual meeting? ...........................................................................

YES

NO

If the response to item 15 is "no", please answer the following:

b.  Was business conducted? .................................................................................................................................

YES

NO

c.  Were elections held? ........................................................................................................................................

YES

NO

d.  Do you permit voting by proxy or mail ballot? .........................................................................................................

YES

NO

16.

complete column 2)

NO. ATTENDING

NUMBER ON

NUMBER

NUMBER

TOTAL NUMBER

RACIAL/ETHNIC

ANNUAL MEETING

NOMINATING

NOMINATED

ELECTED

ON BOARD

GROUP

(Visual Survey)

COMMITTEE

FOR DIRECTOR

AS DIRECTOR

OF DIRECTORS

(1)

(2)

(3)

(4)

(5)

MALE

FEMALE

MALE

FEMALE

MALE

FEMALE

MALE

FEMALE

MALE

FEMALE

a.

American Indian or Alaska Native

b.

Asian

c.

Black or African American

d.

Native Hawaiian or Other Pacific Islander

e.

White

f.

Hispanic or Latino

g.

Other

TOTAL

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

PART III.  SIGNATURES

Type name above

Type name above

WILLFULLY FALSE STATEMENTS ON THIS REPORT ARE PUNISHABLE BY LAW (U.S. CODE TITLE 18 SECTION 101)