Determination Of Nondiscrimination Status Organizations and Groups	AFFACT-03 10-1-2014
Organization /Group requesting assistance
Type of assistance requested
Present program at meeting
Other (Describe)
Request granted – Organization/Group determined to be nondiscriminatory
Assurance by officer/leader
Other (Describe)
Request Denied	Reason
County Extension Agent Name (print)
Signature County Extension Agent	Date