‘£ ry COMPLAINT FORM TO REPORT A HATCH ACT VIOLATION
5 3 For instructions or questions, call the Hatch Act Unit at (202) 804-7002.

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4 Add / Delete a Complaint PART 5: ATTACHMENTS TO YOUR COMPLAINT
ore Tas Weel VENTS Ht [7] | would like to attach documents to my complaint.

Hatch Act)

{ - l : 7 Please attach documents and/or evidence that support your allegations. Note that
About Filing a Complaint the space available for attachments is limited, and you will have an opportunity to
Biographical Information | make additional submissions at a later date.

. . To see the attachments that have been successfully added to your form, click on
Information about Subject the paperclip icon in the dark gray panel on the far left side of your screen.
Alleged Violation Please note that, if you print a copy of your form, the attachments will not print with

a it. However, any documents that appear in the paperclip panel [@ will be
Other Actions transmitted to OSC.
Attachments
Consent PART 6: OTHER ACTIONS YOU ARE TAKING
Certification "| Please indicate in this section if you have reported your matter through other agencies
— or organizations. If so, please identify the agency or organization to which you reported
Submission the matter and provide the current status. If you have received responses regarding
your matter, briefly summarize what results were communicated to you and provide
our office with copies of any correspondence.
PART 7: CONSENT TO DISCLOSURE OF INFORMATION
* Denotes Required Fields
Do you consent to the disclosure of your identity to others outside OSC if it
becomes necessary in taking further action on the mater?

CJ I consent to the disclosure of my identity on a need-to-know basis.

CJ | do not consent to the disclosure of my identity. (I understand my lack of consent
may prevent OSC from taking further action on my complaint. Even if | do not
consent, OSC may disclose my identity if required by law.)

|
|
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OSC Form-14 ‘OMB No. 3255-0005
PROHIBITED POLITICAL ACTIVITY COMPLAINT FORM Expires 02/29/2020

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COMPLAINT FORM TO REPORT A HATCH ACT VIOLATION
For instructions or questions, call the Hatch Act Unit at (202) 804-7002.

c. Please provide the name and contact information for an individual who has

knowledge about the federal fund(s) at issue and whom OSC may contact:

Improper Political Activities Name:
(Hatch Act)
About Filing a Complaint Agency :
Biographical Information Position Title:
Information about Subject Office Telephone: Fax:
Alleged Violation 7
Email Address:
Other Actions
Attachments PART 4: ALLEGED VIOLATION
Consent _ . * Denotes Required Fields
[ec ertification 41. For complaints involving a Subject employed by a state, local, D.C., or nonprofit
Submission agency, which of the following actions are you alleging?*
re FJ Using one’s official authority or influence for the purpose of interfering with or
affecting the result of an election.
(1 Coercing, attempting to coerce, commanding, or advising a state or local officer or
employee to pay, lend, or contribute anything of value to a party, committee,
| organization, agency, or person for political purposes.
[Being a candidate in a partisan election.
2. Please provide a detailed description of the alleged violation(s) and attach/enclose
any supporting documentation with your complaint filing. To process your complaint,
you must provide as much detailed information as possible. Without sufficient
information, we may be unable to investigate your allegation(s).*
A detailed description should include:
a. What the Subject did that allegedly violated the Hatch Act;
b. Where the alleged violation(s) occurred;
c. When the alleged violation(s) took place; and
d. Who else has knowledge that the alleged violation(s) occurred and their relationship
to the Subject.
For instance, a complaint alleging that the Subject is a candidate in a partisan election
for public office should include: the name of the office which the Subject seeks (for
example, Council of the District of Columbia or Mayor of Baltimore, Maryland); the date
of the election; the type of election (primary, special, or general); and how the election
is partisan (for example: candidates are running with political party affiliation). Please
note that the Hatch Act does not prohibit candidacy in a nonpartisan election. (Limit
3000 characters) ‘
OSC Form-14 oe a _ - OMB No. 3255-0005
PROHIBITED POLITICAL ACTIVITY COMPLAINT FORM Expires 02/29/2020

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U.S. Office of Special Counsel

a

Neey

4 Add / Delete a Complaint * Denotes Required Fields
Improper Political Activities CJ | certify that all of the statements made in this complaint are true, complete, and

(Hatch Act)
Certification

correct to the best of my knowledge and belief. | understand that a false statement
or concealment of a material fact is a criminal offense punishable by a fine,
imprisonment, or both 18 U.S.C..§ 1001

— | BURDEN: The burden for this collection of information (including the time for
| reviewing instructions, searching existing data sources, gathering the data needed,
and completing and reviewing the form) is estimated to be an average of one hour to
submit a disclosure of information alleging agency wrongdoing, one hour and fifteen
minutes to submit a complaint alleging a prohibited personnel practice or other
| prohibited activity, or 30 minutes to submit a complaint alleging prohibited political
activity. Please send any comments about this burden estimate, and suggestions for
reducing the burden, to the U.S. Office of Special Counsel, General Counsel's Office,
1730 M Street, NW, Suite 218, Washington, DC 20036-4505.
| OTHER INFORMATION: An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid
OMB control number.

Submission

PLEASE KEEP A COPY OF YOUR COMPLAINT, ANY SUPPORTING
DOCUMENTATION, AND ANY NTI E INS THAT YO! IND
TO OSC N IME WHILE YOUR INT IS PENDING.

REPRODUCTION CHARGES UNDER THE FREEDOM OF INFORMATION ACT
MAY APPLY TO ANY REQUEST YOU MAKE FOR COPIES OF MATERIALS THAT}
YOU PROVIDED TO OSC.

U.S. Office of Special Counsel
1730 M Street, NW
Suite 218

| Washington, DC 20036

|
| If you would like to print and mail your complaint, please address it to:
|

se

OSC Form-14 : : OMB No. 3255-0005
Expires 02/29/2020


‘COMPLAINT FORM TO REPORT A HATCH ACT VIOLATION
= For instructions or questions, call the Hatch Act Unit at (202) 804-7002.

PART 1: IMPORTANT INFORMATION ABOUT FILING A COMPLAINT

a pines INSTRUCTIONS FOR FILING A HATCH ACT COMPLAINT WITH THE U.S. OFFICE
Improper Political Activities OF SPECIAL COUNSEL (OSC)

ee) This fc should be d to fil laints alleging violati f the Hatch Act. I
a is form should be used to file complaints alleging violations of the Hatch Act. In
About Filing a Complaint order for us to best understand your allegations, we encourage you to fill in all the
Biographical Information fields that you can. However, only those fields marked with an asterisk are required.
If you fail to fill in a required field, your complaint cannot be processed. When
| providing information, please be as specific as you can, provide as much detail as
| Alleged Violation | possible, and attach/enclose all supporting documentation with your complaint filing. |
. Prior to submitting your complaint to OSC, we recommend you review the information |
| Other Actions | located on our website . If you have any questions about this form, you may phone
Attachments | the Hatch Act Hotline at (202) 804-7002.

| Consent |
Certifi

| Submission

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Information about Subject

| PART 2: BIOGRAPHICAL INFORMATION
| * Denotes Required Fields
i

| Title
| First Name Middle Initial

| | Last Name

2. Contact Information:

| Address Location [7] Domestic [] International

| Address Line 1
Address Line 2

| city State
Zip Code

| Cell Phone Number

| Office Phone Number Ext.

| Home Phone Number
Email Address
Preferred means of contact:
[email [J home phone [J cellphone (J office phone
( Please do not contact me on my office phone

3. Do you have representation? []Yes [-]No

OSC Form-14 OMB No, 3255-0005
PROHIBITED POLITICAL ACTIVITY COMPLAINT FORM Expires 02/29/2020

Page 1 of 5



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4 Add / Delete a Complaint

Improper Political Activities
(Hatch Act).

About Filing a Complaint
Biographical Information
Information about Subject
Alleged Violation

Other Actions
Attachments

Consent

COMPLAINT FORM TO REPORT A Haren ACT VIOLATION

4. Are you referring this complaint on behalf of a government agency?

(Yes []No

PART 3: INFORMATION ABOUT THE INDIVIDUAL WHO
ALLEGEDLY VIOLATED THE HATCH ACT (Subject)

* Denotes Required Fields
Subject's Employment Status:*
(Federal government employee
State or Local government employee
(Private, Nonprofit organization employee

Title:

Certification . . . . a.
— == Subject's First Name:* Subject's Middle Initial:

Submission SEES —_

— ~~ | Subject's Last Name:*
Employer:*
Position Title:
Subject's Address* [] Domestic [_] International
Office Telephone: Ext.
Home Telephone: Other Telephone:
Email Address:
Does the Subject have knowledge of the Hatch Act?:*
[Yes ([JNo [Unsure
If yes, please explain why you believe the Subject knows about the Hatch Act (for
example: agency training, agency distribution of brochures, flyers, e-mails, prior
contact with OSC):

|

|

|

|

OSC Form-14- a OMB No. 3255-0005

PROHIBITED POLITICAL ACTIVITY COMPLAINT FORM

Page 2 of 5

Expires 02/29/2020


COMPLAINT FORM TO REPORT A HATCH ACT VIOLATION
For instructions or questions, call the Hatch Act Unit at (202) 804-7002.

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Add / Delete a Complaint

Improper Political Activities
(Hatch Act)

SUBJECT’S SUPERVISOR’S INFORMATION

Subject’s Supervisor's First Name:

Subject’s Supervisor's LastName:

About Filing a Complaint
Biographical Information | Subject's Supervisor's Middle Initial:
Information about Subject Subject's Supervisor's Title:
Alleged Violation Office Telephone: Ext.
Other Actions
Other Telephone: Fax:
Attachments
Consent Email Address:
Certification FEDERAL FUNDING INFORMATION
ae SION ______________| 1, Does the Subject’s employer receive any federal funds?: [Yes [No
| 2. Is the Subject’s salary paid entirely with federal funds?: ClYes [No

3. Does the Subject perform any duties in connection with a ClYes [No
federally funded activity?:,

If you answered “No” to both Questions 2 and 3, OSC does not have jurisdiction over

your complaint. If you answered “Yes” to either Question 2 or 3, please provide the

information requested below in as much detail as possible.

a. Please describe the duties the Subject performs in connection with the federally
funded activity and attach/enclose any supporting documentation with your
complaint filing:

b. Please describe the federal funding with which the Subject has a connection and
attach/enclose any supporting documentation with your complaint filing :

The following questions are provided to assist you in describing the nature and
source of the federal funds at issue:
-What is the name of the federal agency that awarded, distributed, or administered
the funds in question?
-What is the name and/or number of the federal grant or loan?
-What is the purpose of the federal funding? (i.e., how are the funds used?)
|
|
OSC Form-14 —_ - "OMB No. 3255-0005
PROHIBITED POLITICAL ACTIVITY COMPLAINT FORM Expires 02/29/2020

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