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U.S. DEPARTMENT OF THE TREASURY INDIVIDUAL COMPLAINT OF (Department of the Treasury - U.S. Mint)

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U.S. DEPARTMENT OF THE TREASURY
INDIVIDUAL COMPLAINT OF EMPLOYMENT DISCRIMINATION FORM INSTRUCTIONS
TDF 62-03.5 (REV. 11/2015 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 le a formal complaint of 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 (40 years or older at the time of
the event giving rise to your claim), disability, protected genetic information, or in reprisal for opposition
to activities protected by civil rights statutes or participating in the EEO process, 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. A ccordingly, 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 notied 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 sufcient 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 disqualied if such representation would conict with the ofcial
or collateral duties of the representative. No EEO Counselor, EEO Investigator or EEO Ofcer 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 led 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 TDF 62-03.5, Individual 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 USC § 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;
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 or LGBT), national origin, age, disability, protected genetic information, parental status, or
retaliation. 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.
6.
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 62-03.5 (11/12/2015 Edition) For Office Use Only:
Department Formal Case Number
Filing Date
INDIVIDUAL COMPLAINT OF
EMPLOYMENT DISCRIMINATION WITH
THE DEPARTMENT OF THE TREASURY
PART I: COMPLAINANT IDENTIFICATION
1. Name
Last Name First Name Middle Initial
2. Primary Contact Number (Include Area Code)
Phone
Best Time to Call: Morning Afternoon Evening
3. Preferred Email Address
Email
4. Home Address (You 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 Retired 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 Address
Firm / Organization
Street Address City State ZIP
10. Representative’s Employer (If Federal Agency)
Employer
11. Representative’s Telephone/Email Address
Phone Email
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. (A) Describe the action taken against you that you believe was discriminatory; (B) Give the date when the action
occurred, and the name of each person responsible for the action; (C) Describe how you were treated differently
than other employees or applicants; (D) Indicate what harm, if any, came to you in your work situation as a result
of this action. (Evidence in support of your claim(s) should be provided to the investigator at a later stage. If you
require more space to describe your allegations, please attach an additional page(s) to this form upon submission.)
Sexual Orientation
15. Mark below ONLY the bases you believe were relied on to take the actions described in #14.
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
16. What remedial or corrective action are you seeking to resolve this matter?
PART IV: CONTACT
17. When did the most recent discriminatory event occur?
Date of Most Recent Event
18. When did you first become aware of the alleged discrimination?
Date of Awareness
19. When did you contact an EEO Counselor?
Date of EEO Contact
Name of EEO Counselor EEO Counselor Phone or Email
20. Did you discuss all actions raised in item 14 with an EEO Counselor?
Yes No
(If no, please explain)
21. When did you receive your Notice of Right to File?
Date Recieved Notice
22. 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.
23. On this same matter, have you filed a grievance or appeal under:
Negotiated grievance procedure
Yes No
Agency grievance procedure
Yes No
MSPB appeal procedure
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: SIGNATURE
24. 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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