Fillable Privacy Act Statement (Department of the Treasury - U.S. Mint)

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Privacy Act Statement (Department of the Treasury - U.S. Mint)

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Privacy Act Statement
AUTHORITY: 29 U.S.C. § 206(d); 29 U.S.C. § 791; 42 U.S.C. § 2000e; 42 U.S.C. § 2000ff-(2);
29 U.S.C. § 633a; 5 U.S.C. § 1303-1304; 5 CFR § 5.2-5.3; 29 CFR § 1614.105, .107; Executive
Order 11478, as amended; and Executive Order 13152 and Management Directive 110 (August
2015).
PRINCIPAL PURPOSE(S): This information is being collected for the sole purpose to record a
complaint allegation of employment discrimination with the Department of the Treasury on the
grounds of race, color, religion, sex (including pregnancy, sexual orientation and gender
identity), national origin, age, disability, protected genetic information, parental status, or reprisal.
An employee or applicant must participate in pre-complaint EEO counseling to informally resolve
the allegation(s) per § 1614.105, prior to filing a formal EEO complaint of discrimination. The
purpose of this form is for the aggrieved to designate his/her Representative in connection with
any and all currently pending informal/formal EEO discrimination complaints unless indicated
otherwise. The information captured on this form will be used by the Department of the Treasury
to serve upon the designated representative any information concerning the aggrieved
complaint(s) of discrimination, including correspondence, copies of documents, reports of
investigations, or reports of hearings to which the aggrieved is entitled under EEOC or Treasury
regulation pertaining to complaints of discrimination; and, to negotiate and finally resolve, adjust
and/or settle any and all of the aggrieved's pre-complaint/formal EEO discrimination complaint(s).
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under
5 U.S.C. §552a(b) of the Privacy Act of 1974, as amended. This includes using this information
as necessary and authorized by the routine uses published in Treasury 013--Department of the
Treasury Civil Rights Complaints and Compliance Review Files system of records notice (FR
Doc No: 2011-22977).
PAPERWORK REDUCTION ACT STATEMENT: In accordance with the Paperwork Reduction
Act of 1995, The Department of the Treasury may not conduct or sponsor, and the respondent is
not required to respond to this collection of information unless it displays a valid OMB Control
Number. The valid OMB Control Number for this information collection is 1505-0262. The
collection of this information is voluntary. However, the information is necessary to determine if
your complaint of employment discrimination is acceptable for further processing in accordance
with EEOC, 29 C.F.R. §1614. The time required to complete this information collection is
estimated to average 5 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing the
form. Send comments regarding this burden estimate or any other aspects of this collection,
including suggestions for reducing this burden, to Department of the Treasury, Office of Civil
Rights and Diversity, 1500 Pennsylvania Avenue, N.W., Washington, DC 20220.
TD F 62-03.2
Revised 2/2017
___________________________________________ _____________________
_______________________________________________________________________
_____________________________________________
____________
_______________________
_____________________________________________
_______
_____________________________________
________________
_________________________________________________________
OMB No. 1505-0262
Expiration Date: 03/21/2022
Department of Treasury
United States Mint
Complaint Number: __________________________
DESIGNATION OF REPRESENTATIVE
I hereby appoint the following named individual or organization as my Representative
for my EEO complaint of discrimination:
Name (Individual or Organization)
Telephone No.
Address (Number and Street)
City
State
Zip Code
Email Address
Yes
No
Is the above named individual a licensed practicing attorney?
_______
I have discussed with my Representative his/her authorization to represent me in
connection with any and all of my currently pending EEO discrimination complaints.
Unless indicated otherwise, my Representative is authorized to:
1. Appear, assist and counsel me in the preparation of my informal/formal EEO
discrimination complaint(s);
2. Appear for me or with me in pre-complaint interviews, mediation, and at hearings or
other proceedings when his/her presence is authorized by EEOC, Treasury
regulation, or by collective bargaining agreement;
3. Receive any information concerning my complaint(s) of discrimination, including
correspondence, copies of documents, reports of investigations, or reports of
hearings to which I am entitled under EEOC or Treasury regulation pertaining to
complaints of discrimination; and,
4. Negotiate and finally resolve, adjust and/or settle any and all of my informal/formal
EEO discrimination complaint(s).
Date
Signature of Aggrieved
Print Name
TD F 62-03.2
Revised 2/2017
1 of 2
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CANCELLATIONS OF DESIGNATION
1.
This designation of representative may be cancelled by the aggrieved or by the
individual named above upon written notice to the Bureau EEO Counselor and the
EEO Office, if cancellation occurs during the informal complaint process. If the
cancellation occurs during the formal complaint process, please notify the Office of
Civil Rights and Diversity.
2.
A subsequent designation of representative, if properly executed on this, or a similar
form, must be sent to the Bureau EEO Office, during the informal complaint process,
or the Office of Civil Rights and Diversity, during the formal complaint process.
3.
The aggrieved is responsible for notifying his/her representative, the EEO Office and
the Office of Civil Rights and Diversity when the designation of representative is
cancelled.
TD F 62-03.2
2 of 2
Revised 2/2017
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Privacy Act Statement (Department of the Treasury - U.S. Mint)

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Completed 26 January 2021

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