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NOTICE OF APPEAL/PETITION - COMPLAINANT

Management Directive 110

TO THE EQUAL EMPLOYMENT OPPORTUNITY COMMISSION
OFFICE OF FEDERAL OPERATIONS
P.O. Box 77960
Washington, DC 20013

Complainant Information: (Please Print or Type)

Complainant's name (Last, First, M.I.):

Home/mailing address:

City, State, ZIP Code:

Daytime Telephone # (with area code)

E-mail address (if any):

Attorney/Representative Information (if any):

Attorney name:

Non-Attorney Representative name:

Address:

City, State, ZIP Code:

Telephone number (if applicable):

E-mail address (if any):

General Information:

Name of the agency being

charged with discrimination:

Identify the Agency's complaint number:

Location of the duty station or local facility in which the complaint arose:

Has a final action been taken by the agency, an Arbitrator, FLRA, or MSPB on this complaint?

□ Yes Date Received ____________ (Remember to attach a copy)

□ No

□ This appeal alleges a breach of a settlement agreement

Has a complaint been filed on this same matter with the Commission, another agency, or through any other administrative or collective bargaining procedures?

□ No

□ Yes (Indicate the agency or procedure, complaint/docket number, and attach a copy, if appropriate)

Has a civil action (lawsuit) been filed in connection with this complaint?

□ No

□ Yes (Attach a copy of the civil action filed)

NOTICE: Please attach a copy of the final decision or order from which you are appealing. If a hearing was requested, please attach a copy of the agency's final order and a copy of the Commission Administrative Judge's decision. Any comments or brief in support of this appeal MUST be filed with the Commission and with the agency within 30 days of the date this appeal is filed. The date the appeal is filed is the date on which it is postmarked, hand delivered, submitted, or faxed to the Commission at the address above.

Please specify any reasonable accommodations you will require to participate in the appeal process:

Signature of complainant or complainant's representative:

Date:

Method of Service on Agency:

Date of Service:

PRIVACY ACT STATEMENT ON REVERSE SIDE.

EEOC Form 573 REV 2/09

PRIVACY ACT STATEMENT

(This form is covered by the Privacy Act of 1974. Public Law 93-597. Authority for requesting the personal data and the use thereof are given below)

  1. FORM NUMBER/TITLE/DATE: EEOC Form 573, Notice of Appeal/Petition, February 2009
  2. AUTHORITY: 42 U.S.C. § 2000e-16
  3. PRINCIPAL PURPOSE: The purpose of this questionnaire is to solicit information to enable the Commission to properly and effectively adjudicate appeals filed by federal employees, former federal employees, and applicants for federal employment.
  4. ROUTINE USES: Information provided on this form may be disclosed to: (a) appropriate federal, state, or local agencies when relevant to civil, criminal, or regulatory investigations or proceedings; (b) a Congressional office in response to an inquiry from that office at your request; and (c) a bar association or disciplinary board investigating complaints against attorneys representing parties before the Commission. Decisions of the Commission are final administrative decisions, and, as such, are available to the public under the provisions of the Freedom of Information Act. Some information may also be used in depersonalized form as a database for statistical purposes.
  5. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL FOR NOT PROVIDING INFORMATION: Since your appeal is a voluntary action, you are not required to provide any personal information in connection with it. However, failure to supply the Commission with the requested information could hinder timely processing of your case, or even result in the rejection or dismissal of your appeal.

You may send your appeal to:

The Equal Employment Opportunity Commission
Office of Federal Operations
P.O. Box 77960
Washington, DC 20013

Fax it to (202) 663-7022 or submit it through the Commission's electronic submission portal.