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U.S. DEPARTMENT OF THE TREASUR
Y
COMPLAINT OF CLASS DISCRIMINATION FORM INSTRUCTIONS TD F 62-03.10
(REV. 02/2017
EDITION)
(Read the following instructions carefully before you complete this form)
(Please complete all items on the complaint form)
GENERAL: This form is to be used to file a formal complaint of class discrimination if you are an applicant for
employment with the Department of the Treasury, or a present or former Department of the Treasury employee and:
1) believe you have been discriminated against because of your race, color, religion, sex (including
pregnancy, sexual orientation and gender identity), national origin, age, disability, protected genetic
information, or in reprisal,
or
2) believe you have been discriminated against because of your parental status. Your claim is not covered
under a statutory basis, but will be processed under a parallel procedure.
IMPORTANT NOTE: In certain situations, the information provided in Part III of the attached complaint form
may be used in lieu of an affidavit in the investigation of your complaint. Accordingly, the information you
provide in this part should be brief, clear, and complete.
WHEN TO FILE: In accordance with 29 CFR 1614.106, your formal complaint must be filed within 15 calendar
days of the date you received the Notice of Right to File a Discrimination Complaint form from your EEO
Counselor. You must sign and date your complaint. If you are represented
by an attorney, the attorney may sign
the complaint on your behalf.
This time limit may be extended:
1) if you show that you were not notified of the time limits and were not otherwise aware of them, or
2) if you were prevented by circumstances beyond your control from submitting the matter within the time
limit, or
3) for other reasons considered sufficient by the Department.
REPRESENTATION: You may have a representative of your own choosing at all stages of the processing of your
complaint. However, your representative will be disqualified if such representation would conflict with the official or
collateral duties of the representative. No EEO Counselor, EEO Investigator or EEO Officer may serve as a
representative. (Your representative need not be an attorney, but only an attorney representative may sign the
complaint on your behalf.)
WHERE TO FILE: In accordance with 29 CFR 1614.106(c), your written complaint must be signed by you or your
attorney. The complaint should be filed with the Department of the Treasury. (Filing instructions are contained in
the “Notice of Right to File” letter, which was provided by your EEO Counselor.) Keep a copy of the completed
complaint form for your records.
PRIVACY ACT STATEMENT
1. FORM NUMBER/TITLE/DATE: Department of the Treasury Form Number TD F 62-03.10, Class Complaint of
Employment Discrimination with the Department of the Treasury (10/15 Edition).
2.
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 C.F.R. § 1614.103(a); 29 CFR § 1614.105; .107; 29
C.F.R. §1614.204; Executive Order 11478, as amended; Executive Order 13152 and Management Directive
110 (August
2015).
3.
PRINCIPAL PURPOSES: The purpose of this complaint form, whether recorded initially on the form or taken
from a letter from the Complainant, is to record the filing of a formal written complaint 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. Information provided on this form will be used by the Department of
the Treasury to determine whether the complaint was timely filed and whether the allegations in the
complaint are within the purview of 29 CFR Part 1614, or the Executive Orders listed in item 2 above, to
provide a factual basis for investigation of the complaint, and to reach a decision on the complaint. This
form may also be used to record an amendment request or additional evidence for an open, pending
complaint.
4.
ROUTINE USES: Disclosures may be made consistent with the routine uses published in applicable Systems
of Record Notices, including EEOC/GOVT-1 and Treasury .013. These routine uses include:
a. to respond to a request from a Member of Congress regarding the status of the complaint or appeal;
b. to respond to a court subpoena and/or to refer to a district court in connection with a civil suit;
c. to disclose information to authorized officials or personnel to adjudicate a complaint or appeal; or
d. to disclose information to another Federal agency or to a court or third party in litigation when the
Government is party to a suit before the court.
5.
WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY, AND EFFECT ON INDIVIDUAL BY NOT PROVIDING
INFORMATION
: Formal complaints of employment discrimination must be in writing, signed by the
Complainant (or attorney representative), and must identify the parties and action or policy at issue. Failure
to comply may result in the Department of the Treasury dismissing the complaint. It is not mandatory that
this form be used to provide the requested information.
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.
DETACH AND KEEP THIS PAGE WHEN YOU FILE YOUR COMPLAINT.
OMB No. 1505-0262
Expiration Date: 03/21/2022
Form No. TD F
62-03.10
For Office Use Only:
Department Formal Case Number
Filing Date
COMPLAINT OF CLASS
DISCRIMINATION WITH THE
DEPARTMENT OF THE TREASURY
PART I: CLASS AGENT IDENTIFICATION
1. C l a s s A g e n t Name
Last Name
First
Name
Middle Initial
2. Primary Contact Number (Include Area Code)
Phone
3. Preferred Email Addr
ess
Email
4. Home Address
(
Y
ou must notify the Department of any changes of address or your complaint may be dismissed.
Send updated information to: Office of Civil Rights and Diversity, Department of the Treasury, 1500 Pennsylvania
Avenue NW, Washington, DC 20220.)
Street Address
City
State
ZIP
5. If you are a current or former employee of the Federal government, list your most recent title, series, and grade.
Title
Series
Grade
6. Name and Address of Organization Where You Work (if a Treasury Employee)
Bureau
and
Business
Unit
Office
and
Organizational
Component
Street Address
City
State
ZIP
7. Employment Status in Relation to this Complaint:
Applicant
Probationary Career/Career Conditional
Former
Employee
Retir
ed Other:
Date Left
Treasury Employment (if
applicable)
PART II: DESIGNATION OF REPRESENTATIVE
8. You may represent yourself in this complaint or you may choose someone to represent you. Your representative does
not have to be an attorney. You may change your designation of a representative at a later date, but you must notify the
department immediately in writing of any change, and you must include the same information requested in this Part.
“I hereby designate
(Please
Print
Name)
to serve as my representative
during the course of this complaint. I understand that my representative is authorized to act on my
behalf.”
9. Representative’s Mailing Addr
ess
Firm
/ Organization
Street Address
City
State
ZIP
10. Representative’s Employer (If Federal Agency)
Employer
11. Representative’s Telephone/Email Addr
ess
Phone
PART III:
ALLEGED
DISCRIMINATORY ACTIONS
12. Name and Address of Treasury Bureau that took the action at issue (if different than item 6.)
Bureau
and
Business
Unit
Office
and
Organizational
Component
Street Address
City
State
ZIP
13. If your complaint involves nonselection for a position, please complete the below information. If you wish to allege
more than one nonselection, list the same information for each additional nonselection under number 14.
Position
Series
Grade
Vacancy Announcement
Number
Date
Learned
of Nonselection
14. I D E N T I F I C AT I O N O F C L AS S ( P r o v i d e t h e n a m e o f eac h c las s m e m b e r o r t h e g r ou p t o
w h i c h t h e c l as s b e l ong s a n d ind i ca t e r ace , c o l o r , r e li g i on , sex (pregnancy, sexual
orientation, and gender identity), n a t i on a l o r i g in , age, disability, protected genetic
information, parental status or reprisal and other pertinent information, including the
employment status, and job titles ). If additional space is required, continue on blank sheet.
15. D E S C R I P T I O N I N D I V I D U AL A L L E G AT I O N O F D I S C R I M I N A T I O N O F T H E AG E N T ( B e
s p e c i f i c an d d e t a i l e d a s t o t h e a c t i o n o r m a t t e r i n v o l v ed . E x p l a i n , h ow y o u w e r e
a d v e r s e l y a f f e c t e d , e t c . ) I f a d d it i o n a l s p a c e i s r e q u i r e d , c o n t i n u e o n b l a n k s h e e t
16. D E S C R I P T I O N C L A S S AL L E G AT I O N O F D I S C R I M I N A T I O N (B e s p e c i f i c a n d d e t a i l e d
a n d d e s c r i b e t h e s p e c i f i c p o l i c y o r p r ac t i c e a l l e g e d as d i s c r i m i n a t o r y a n d t h e
T r e a s u r y o r g a n i z a t i o n i n v o l v e d i n i m p l e m e n t i n g t h e p o l i c y o r p r a c t i c e . ) I f a d d i t i o n a l
s p a c e i s r e q u i r e d , c o n t i n u e o n b l a n k s he e t
17. Mark below ONLY the bases you believe were relied on to take the actions described in #15 and 16.
Age (Date of Birth:
)
Race (State Race:
)
Color (State Color:
)
Religion (State Religion:
)
Sex
(
Male
Female)
Pregnancy
Sexual Orientation
Gender Identity
National Origin (Specify:______________________
)
Disability
Protected Genetic Information
Retaliation/Reprisal
(Date of Prior
EEO
Activity: _________________
)
Parental Status
18. What remedial or corrective action are you seeking to resolve this matter?
PART
IV:
CONT
ACT
19. When did the most recent discriminatory event
occur?
Date of Most
Recent
Event
20. When did you first become aware of the alleged discrimination?
Date of Awareness
21. When did you contact an
EEO
Counselor?
Date of
EEO
Contact
Name of
EEO
Counselor
EEO Counselor Phone
or Email
22. Did you discuss all actions raised in item 15 and 16 with an
EEO
Counselor?
Yes No
(If
no,
please
explain)
23. When did you receive your Notice of Right to File?
Date
Recieved
Notice
24. If you contacted an
EEO
Counselor more than 45 days after the most recent alleged discriminatory event, or if you
are filing this form more than 15 days after receiving the Notice of Right to File, please provide an explanation
for
the delay below and attach additional supporting documentation if necessary.
25. On this same matter, have you filed a grievance or appeal under:
Negotiated grievance
pr
ocedur
e
Yes No
Agency grievance
pr
ocedur
e
Yes No
Merit System Protections Board appeal
pr
ocedur
e
Yes No
If you filed a grievance or appeal, provide date filed, case number, and present status.
Date Filed
Case
Number
Present
Status
PART
V:
SIGNA
TURE
26. I certify that all of the statements made in this complaint are true, complete, and correct to the best of my
knowledge and belief.
Signature
of
Complainant
or
Attorney
Representative
Date
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Completed 26 January 2021

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