Individual Complaint Of Employment Discrimination Page 2
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4PRIVACY 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
(12/02 Edition).
2. AUTHORITY: 42 USC 2000e; 29 USC 633a; PL 95-062 as amended; 5 USC 1303
and 1304; 5 CFR 5.2 and 5.3; 29 CFR 1614.105 and 1614.107; and Executive Order
11478, as amended, Executive Order 13145; and Executive Order 13152.
3. PRINCIPAL PURPOSES: The purpose of this complaint form, whether recorded init
ially 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, national origin, age, physical or
mental disability, (including protected genetic information), sexual orientation, 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 Execu
tive Orders listed in item 2 above, to provide a factual basis for investigation of the
complaint, and to reach a decision on the complaint. It also records an amendment
or additional evidence to an open, pending complaint.
4. ROUTINE USES: Other disclosures may be:
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;
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.
DETACH AND KEEP THIS PAGE WHEN YOU FILE YOUR COMPLAINT
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