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).
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).
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.
WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY, AND EFFECT ON INDIVIDUAL BY NOT PROVIDING
: 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.