Current Form SSA-437

SOCIAL SECURITY

Office of the General Counsel

You may use the attached discrimination complaint form or a letter to file a Civil Rights complaint with
the Office of the General Counsel for Social Security. If you file a complaint by letter, it must include
the same information requested in the form.
Complaints of discrimination usually must be filed within 180 days of the alleged discrimination. If you
have waited longer than 180 days, you must explain why. OGC will waive the 180 day requirement in
cases where OGC determines there was good cause (extenuating circumstances) for late filing.
Anyone who believes he or she or a class of people have been discriminated against by the Social
Security Administration (SSA) may file a complaint, or may have a representative file such a complaint.
To file a complaint, please mail a completed and signed discrimination complaint and a signed consent
and release to:
Social Security Administration
Office of the General Counsel
Office of General Law
Suite No. 56, P.O. Box 26430
Baltimore, MD 21207
You may also call (410) 965-3166. If you have any questions or wish to discuss this matter, you may
also write to us at the above address or call the above number. We will ensure that the individual's or
group's civil rights are preserved and work to correct any problems we find within SSA.

General Counsel
of Social Security

Enclosures:
Discrimination Complaint Form
Consent and Release Supplemental Form

Form SSA-437-BK (3-2006) EF (3-2006)

PAPERWORK REDUCTION ACT
This information collection meets the requirements of 44 U.S.C. & 3507, as amended by section 2 of the
Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of
Management and Budget control number. We estimate that it will take about an hour to read the instructions,
gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. To find the nearest office, call 1-800-772-1213. Send only comments on our time estimate
above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.

USES OF PERSONAL INFORMATION FOR INVESTIGATIONS
The information collection is authorized by 5 U.S.C. § 301; 29 U.S.C. §791 et. seq.; 42 U.S.C. §§902(a)(5),
1305 note. Those statutes require the agency not to discriminate on the basis of disability and authorize the
Commissioner establish policies to prohibit Social Security Administration and SSA employees from discriminating
based upon race, color national origin, sex, age, religion, or retaliation in any program or activity conducted by
SSA,
There are two federal laws governing personal information given to all Federal agencies, including the Office of the
General Counsel (OGC):
• The Privacy Act of 1974, (U.S.C. Sec. 522a); and
• The Freedom of Information Act, (5 U.S.C. Sec. 522).
The Privacy Act protects individuals from misuse of personal information held by the Federal government. The law
applies to records that are kept and that can be located by the name, social security number, or other personal
identification system.
OGC will use personal information for authorized civil rights activities and other Privacy Act routine uses. Generally,
OGC will not release information unless the person who supplied the information submits a written consent, or
unless release is required under the Freedom of Information Act or other Federal statute or regulation. However,
OGC can refer complaints to other Federal agencies, such as the Department of Justice, the Department of Labor
and the Equal Employment Opportunity Commission, without the person's prior consent.
This authority is
provided under the "routine use" exception of the Privacy Act.
OGC may give/release information to other government agencies, such as the Department of Justice, when an SSA
component has violated civil rights laws or regulations.
OGC cannot require a person to give personal information, and OGC will not impose sanctions on a person who
refuses to provide personal information. However, if, as a result of this refusal, OGC cannot investigate the
allegations of discrimination, OGC may close the investigation.
The Freedom of Information Act (FOIA) gives the public the right of access to files and records of the Federal
government. With some exceptions, SSA must honor FOIA requests, though our policy is to do so without
releasing a person's name or other personal information (as opposed to identification). SSA is generally not required
to release documents if the release would interfere with SSA's ability to complete its work; as, for example, during
an investigation or enforcement proceeding. Also any Federal agency may refuse a request for files or records if the
release would be an unnecessary invasion of an individual's privacy.

Form SSA-437-BK (03-2006 EF (03-2006)

Form Approved
OMB No. 0960-0585

Social Security Administration
Discrimination Complaint
Person Allegedly Discriminated Against

Source of Alleged Discrimination/Retaliation

Name

Employee
Name
(First)

(First)

(MI)

(Last)

—
Social Security Number

Address (include City, State, Zip Code)

1.a.

1.b.

2.

(Last)

Office

—

Daytime phone number where you can be reached

(MI)

Address (include City, State, Zip Code)

(

)

Which of the following best describes the basis for the discrimination? (You may check more than one
reason.)

DISABILITY

AGE

RACE

SEX

COLOR

RELIGION

NATIONAL ORIGIN

RETALIATION

For each reason you checked above, please specify the particular disability, race, sex, etc.

Describe the act(s) of discrimination. (Clearly explain what happened and why. Be sure to include how
other persons were treated differently from you or the person discriminated against. You may use extra
paper if necessary.)

Form SSA-437-BK (03-2006) EF (03-2006)

Page 2

3.

If you believe there was retaliation against you for filing or participating in a prior discrimination complaint,
please explain the basis for the retaliation below.

4.a.

When did the current alleged discrimination take place?

Earliest Date

Most Recent Date

Month/Day/Year

Month/Day/Year

4.b.

Have you waited more than 180 days since the most recent date of the alleged discrimination to file this
complaint? If so, please explain why. (You may use additional paper if necessary.)

5.a.

Have you filed a complaint about the same incident(s) with the Office of the General Counsel (OGC)
before?
Yes

5.b.
5.c.

6.a.

No

If yes, when:

Month/Day/Year

What is the status of that prior complaint?

Have you filed a complaint about any prior incident with OGC before?
Yes

No

6.b

If yes, when:

6.c.

What is the status of that prior complaint?

Month/Day/Year

Form SSA-437-BK (03-2006) EF (03-2006)

Page 3

7.

Please list the names, addresses and phone numbers of any witnesses to the alleged incident(s), including
Social Security employees:
Name

8.a.

Address

Have you tried to resolve this complaint with the Social Security office where the alleged discrimination
took place?
Yes

No

8.b.

If not, why not?

8.c.

If yes, what happened?

8.d.

Name and title of the manager/supervisor who handled the complaint:
Name
Title

9.a.

Phone Number

Have you made a complaint about this anywhere else?
Yes

No

9.b.

If yes, name of organization.

10.

Are you filing this complaint because your benefits were ceased?

Form SSA-437-BK (03-2006) EF (03-2006)

Page 4

11.

Identify Person Filing the Complaint: (Complete if not provided previously)
Name
Address
Daytime phone number where you can be reached

12.

(

)

Dated Signature of Person Filing the Complaint: (Please sign and date the complaint below. We cannot
accept a complaint for investigation if it has not been signed.)
Signature
Date

Month/Day/Year

Form SSA-437-BK (03-2006) EF (03-2006)

Form Approved
OMB No. 0960-0585

Social Security Administration
Discrimination Complaint - Consent and Release
Please complete and sign this consent and release and return the consent and release to the address on the cover
page.
I have read the notice about the need for and uses of personal information to investigate this discrimination
complaint.
Consent: (check one)
I authorize OGC to reveal my identity to conduct the investigation of my complaint.
I do not authorize OGC to reveal my identity to conduct the investigation of my complaint.

Release: (check one)
I authorize the release of material and information about me to OGC to conduct the investigation of my
complaint. (If you want OGC to restrict the release of this information in any way, please explain below
in the comment section.) I further understand that OGC may also disclose this information as required by
other Federal statutes, regulations and Privacy Act routine uses.

I do not authorize the release of material and information about me to OGC to conduct the investigation
of my complaint. (If you want OGC to restrict the release of this information in any way, please explain
below in the comment section.) I further understand that OGC may also disclose this information as
required by other Federal statutes, regulations and Privacy Act routine uses.

Comments:

Signature:

(Please keep a copy of this for your records.)

Form SSA-437-BK-SUPP (03-2006 ) EF (3-2006)

Date: