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 pre-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. Information provided on this form will be used to inform the aggrieved that,
because the matters brought to our attention have not been resolved, the aggrieved is now entitled
to file a formal EEO discrimination complaint with the Department of the Treasury. The
information captured on this form will be used by the Department of the Treasury to provide a
factual basis of the allegation(s) discussed during pre-complaint EEO counseling. This form
will also be used to ensure the aggrieved is informed of his/her right to file and to provide
instructions on how and where to file a formal 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: 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 20 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 62-03.8
Revised 2/2017
OMB No. 1505-0262
Expiration Date: 03/21/2022
Department of the Treasury
United States Mint
: ______________________________________
Pre-complaint number: _______________________
From: ________________________________
Notice of Right to File a Formal EEO Discrimination Complaint
contacted an EEO Official to initiate the EEO pre-complaint process
during which you alleged:
if additional space is required, continue on a blank sheet of paper and attach to this form.
If the Aggrieved is represented by an attorney, this form shall be addressed to the representative with a copy to the Aggrieved.
29 C.F.R. § 1614.605(d).
The term “youas it appears in this Notice should be construed to refer to the Aggrieved.
TD F 62-03.8
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This is to inform you that, because the matters brought to our attention have not been resolved, you are
now entitled to file a formal EEO discrimination complaint with the Department of the Treasury.
If you wish to file a formal complaint, it must be in writing signed by you. If your designated representative is an
attorney, s/he may sign on your behalf. The complaint must be filed within fifteen (15) calendar days after
receipt of this Notice. The complaint form and instructions for filing are available here
If you did not contact an EEO Official within 45 days from the date of the matter you allege to be discriminatory,
or if you do not file the formal complaint within 15 calendar days of receipt of this Notice, please use section 22
of the formal complaint form to explain why you did not meet the time requirements. The Department will
evaluate this information when deciding whether to accept your complaint for investigation.
If you believe you were subjected to prohibited age discrimination (40 years of age and older), as an alternative
to filing a complaint under the Equal Employment Opportunity Commission regulations, you may file a civil
action in an appropriate U.S. District Court under the Age Discrimination in Employment Act against the
Secretary of the Treasury, provided that you inform the EEOC of your intent to sue at least 30 calendar days in
advance of filing suit. Such notice must be filed in writing with EEOC, at P.O. Box 77960, Washington, D.C.
20013, or by personal delivery or facsimile within 180 days of the occurrence of the alleged unlawful practice.
If you are filing a claim of discrimination based on sexual orientation or gender identity (LGBT), you may also
elect to file with the Office of Special Counsel (
I certify that on __________________________ , I transmitted this Notice by the following method
(Aggrieved or attorney’s email address)
(EEO Counselors: when sending via email, remember to obtain and add to the record proof of receipt on a
certain date by the Aggrieved or their attorney representative (if designated); e.g., a return email from the
Aggrieved or attorney representative confirming receipt of the Notice, or a copy of the email you sent
showing the Notice attached plus a read receipt.)
Certified Mail
(Tracking Number)
Hand Delivery
(Aggrieved or Attorney’s Signature)
EEO Counselor’s Signature
cc (for Aggrieved when represented):
When the Aggrieved is unrepresented or is represented by a non-attorney, the timeframe for filing is calculated from when
the Aggrieved receives the Notice; when the Aggrieved is represented by an attorney, the timeframe is calculated from when
the attorney receives the Notice. 29 C.F.R. § 1614.605(d). Therefore, the receipt information above tracks receipt of the
Notice by the Aggrieved or when an attorney is designated, by the attorney.
TD F 62-03.8
Revised 2/2017
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