.

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?................................................................................................................................................ o YES o NO

 b. Use of facilities? ..................................................................................................................................................................................... o YES o NO

 c. Access to facilities by disabled persons as required by Federal accessibility standards? ...................................................................... o YES o NO

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

 a. “AND JUSTICE FOR ALL” poster?........................................................................................................................................................ o YES o NO

 b. Statement of Nondiscrimination?............................................................................................................................................................ o YES o NO

3. Were any complaints involving program benefits filed against your organization on the basis of: (if Yes, explain in “COMMENTS”)

 a. Title VI of the Civil Rights Act of 1964? .................................................................................................................................................. o YES o NO

 b. Section 504 of the Rehabilitation Act of 1973 (disability)? ...................................................................................................................... o YES o NO

 c. Age Discrimination Act of 1975 (age) ..................................................................................................................................................... o YES o 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?............................................................................................... o YES o NO

 b. Providing a copy of the Statement of Nondiscrimination to each new:

(1) customer? .......................................................................................................................................................................................... o YES o NO

(2) employee, when hired? ...................................................................................................................................................................... o YES o 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? ........... o YES o NO

 b. Develop and administer equitable line extension and/or security deposit policies for all customers? ..................................................... o YES o NO

c. Have an equitable disconnect policy?...................................................................................................................................................... o YES o NO

6. ELECTRIC BORROWERS ONLY: Does your organization have a means to inform present and potential customers of the

 availability of payment options (budget billing, etc.)? ................................................................................................................................... o YES o 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? ........................................................................................................ o YES o NO

IDENTIFY: Name: ______________________________ 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) ....................................................... o YES o NO

b. Pro-rated based on latest census data .................................................................................................................................................. o YES o NO

 9a. Racial/Ethnic Groups (Use either pro-rated census data

for your service area or your own records): 9b. Total Number of Residential customers at End of

 Calendar Year: _________

 Comments:

RUS Form 268 (Rev. 9-99)

U.S. DEPARTMENT OF AGRICULTURE

Rural Utilities Service

REPORT OF

COMPLIANCE AND PARTICIPATION

 BORROWER DESIGNATION

 NAME OF BORROWER

 INSTRUCTIONS – Submit 2 copies to the appropriate General Field Representative by January 31 for the prior Calendar Year. Each item

must be answered.

PART I. FOR ALL RUS ELECTRIC AND TELECOMMUNICATIONS BORROWERS

 DATE CALENDAR YEAR

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of informaion unless it displays a valid OMB control number. The valid OMB control number for this

information collection is 0572-0047. The time required to complete this information collection is estimated to average 10 hours per resonse, including the time to review instructions, search existing data

resources, gather the data needed, and complete and review the information.

Group

% of Residential

Customers

(must add to 100%)

(1) American Indian or Alaska Native

(2) Asian

(3) Black or African American

(4) Native Hawaiian or Other Pacific Islander

(5) White

(6) Hispanic or Latino

(7) Other

9c. Total Number of Residential Disconnects For

Non-Payment in Calendar Year: _________

9d. Total Number of New Residential Customers

Connected During Calendar Year: _________