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
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 withdraw his/her connection with any and all currently
pending complaints (informal or formal) EEO discrimination complaints unless indicated otherwise.
The information captured on this form will be used by the Department of the Treasury to record
the voluntary decision of the aggrieved to withdraw his/her EEO complaint of discrimination.
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:
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 1 hour 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 62-03.9
Revised 2/2017
OMB No. 1505-0262
Expiration Date: 03/21/2022
Department of the Treasury
United States Mint
Name of the Aggrieved:
Complaint Number:
Notice of Withdrawal from Participation in the EEO Complaint Process
I wish to voluntarily withdraw from the EEO complaint counseling the allegation(s) of
employment discrimination, which I initiated on ___/___/___ . I hereby confirm that I was not
coerced, threatened or intimidated by anyone into withdrawing from the process.
I understand that my voluntary withdrawal terminates the processing of this complaint and I will
not pursue an EEO discrimination complaint on this matter. I understand that I still retain the right
to enter the EEO complaint process for future matters.
I understand that, if I want to file an EEO discrimination complaint in the future, I must contact an
EEO Counselor within 45 days from when I first became aware of the potential discriminatory
Signature of Aggrieved
Signature of EEO Counselor
TD F 62-03.9
Revised 2/2017
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