Form 10 - Statement Concerning Discrimination

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Form 10
FORM 10. Statement Concerning Discrimination
UNITED STATES COURT OF APPEALS FOR THE FEDERAL CIRCUIT
____________________________ v. ____________________________
No. _______
PETITIONER’S FED. CIR. R. 15(c) STATEMENT CONCERNING DISCRIMINATION
Please complete sections A, B, and C.
SECTION A:
Check the statements in section A that apply to your case. Usually, it is one statement,
but it may be more. Do not alter or add to any of the statements.
_____ (1) No claim of discrimination by reason of race, sex, age, national origin, or handi-
capped condition has been or will be made in this case.
_____ (2) Any claim of discrimination by reason of race, sex, age, national origin, or handi-
capped condition raised before and decided by the Merit Systems Protection Board or
arbitrator has been abandoned or will not be raised or continued in this or any other
court.
_____ (3) The petition seeks review only of the Board’s or arbitrator’s dismissal of the case
for lack of jurisdiction or for untimeliness.
_____ (4) The case involves an application to the Office of Personnel Management for benefits.
_____ (5) The case was transferred to this court from a district court and I continue to contest
the transfer.
SECTION B:
Answer the following: Have you filed a discrimination case in a United States district
court from the Board’s or arbitrator’s decision? _____Yes _____No
If so, identify any case. _________________________________________________________
SECTION C:
Answer the following: Have you filed a discrimination case in the Equal Employment
Opportunity Commission from the Board’s or arbitrator’s decision? _____Yes
_____No
If so, identify any case ________________________________________________________
___________________
_________________________________________
Date
Petitioner’s signature
Mail this form with the petition for review or within 14 days of the date of docketing of the
petition for review to:
Clerk of Court
United States Court of Appeals for the Federal Circuit
717 Madison Place, NW
Washington, DC 20439
___________________________________
cc:
125
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