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
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