Individual Complaint Of Employment Discrimination
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4U.S. DEPARTMENT OF THE TREASURY
INDIVIDUAL COMPLAINT OF EMPLOYMENT DISCRIMINATION
FORM INSTRUCTIONS
TDF 62-03.5 (Rev. 01/03 edition)
(Read the following instructions carefully before you complete this form)
(Please complete all items on the complaint form)
GENERAL: This form should be used only if you, as an applicant for employment with the
Department of the Treasury, or as a present or former Department of the Treasury employee:
1) believe you have been discriminated against because of your race, color, religion,
sex, national origin, age (40 years or older at the time of the event giving rise to your
claim), physical or mental disability, or in reprisal for opposition to activities protected by
civil rights statutes, or
2) believe you have been discriminated against because of your parental status, sexual
orientation, or protected genetic information. Your claim is not covered under a statutory
basis, but will be processed under a parallel procedure, and
3) have presented the matter for informal resolution to an Equal Employment Opportunity
(EEO) Counselor within 45 days of the event giving rise to your claim, or within 45 days of
first becoming aware of the alleged discrimination. If you are amending or providing
additional evidence to an existing open complaint, the form should be used, but EEO
counseling is not required.
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.
These time limits 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 limits, 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 repre
sentation would conflict with the official or collateral duties of the representative. No EEO
Counselor or 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 Treasury Complaint Cen
ter responsible for the geographic area in which you work, or, in the case of a former employee
or applicant, where you live. (Filing instructions are contained in the "Right to File" form, which
was provided by your Counselor.) You also may file your complaint with the Director, Office of
Equal Opportunity Program (OEOP), Department of the Treasury, 1500 Pennsylvania Avenue,
NW, Metropolitan Square, Room 6071, Washington, DC 20220. However, this will delay the
processing of your complaint as OEOP will forward your complaint to the appropriate
Center for processing. Keep a copy of the completed complaint form for your records.
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