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U.S. Office of Special Counsel

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| 4 Add / Delete a Complaint |

| Improper Political Activities
| (Hatch Act)

Certification
Submission

OSC Form-14

CERTIFICATION
* Denotes Required Fields
(5 | certify that all of the statements made in this complaint are true, complete, and
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
teducing 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.

PLEASE KEEP A COPY OF YOUR COMPLAINT, ANY SUPPORTING

DOCUMENTATION, AND ANY ADDITIONAL ALLEGATIONS THAT YOU SEND
TO OSC NOW OR AT ANY TIME WHILE YOUR COMPLAINT 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.

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

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

Suite 218

Washington, DC 20036

OMB No. 3255-0005
Expires 02/29/2020


SBC Ly
A q COMPLAINT FORM TO REPORT A HATCH ACT VIOLATION
| A ii For instructions or questions, call the Hatch Act Unit at (202) 804-7002.
aN 4
tarps oF
Bavigationieay For instance, a complaint alleging that the Subject is a candidate in a partisan election
Add / Delete a Complaint | for public office should include: the name of the office which the Subject seeks (for
a5 pane example, Council of the District of Columbia or Mayor of Baltimore, Maryland); the date
a fctwites 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
About Filing a Complaint note that the Hatch Act does not prohibit candidacy in a nonpartisan election. (Limit
Biographical Information 3000 characters)
Information about Subject
Alleged Violation
Other Actions
Attachments PART 5: ATTACHMENTS TO YOUR COMPLAINT
Consent 7 ___| [) I would like to attach documents to my complaint.
Certification Please attach documents and/or evidence that support your allegations. Note that
Submission = the space available for attachments is limited, and you will have an opportunity to
| Supmission _ ————| make additional submissions at a later date.
To see the attachments that have been successfully added to your form, click on
the paperclip icon in the dark gray panel on the far left side of your screen.
Please note that, if you print a copy of your form, the attachments will not print with
it. However, any documents that appear in the paperclip panel LZ will be
transmitted to OSC.
PART 6: OTHER ACTIONS YOU ARE TAKING
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
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?

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

J | do not consent to the disclosure of my identity. (| 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.)

Sc Form-14 a _ OMB No: 3255-0005

PROHIBITED POLITICAL ACTIVITY COMPLAINT FORM

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sree

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

v

Sterns OF

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4 Add / Delete a Complaint PART 1: IMPORTANT INFORMATION ABOUT FILING A COMPLAINT

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

oh i This 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
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.

Biographical Information

Information about Subject

Consent

PART 2: BIOGRAPHICAL INFORMATION
* Denotes Required Fields

1. Complainant Information:
Title
First Name Middle Initial
Last Name

2. Contact Information:
| Address Locatio 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:

{lemail [] home phone [(]cell phone [_] office phone
(J 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

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

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

Add / Delete a Complaint (Yes [No

Improper Political Activities

(Hatch Act) PART 3: INFORMATION ABOUT THE INDIVIDUAL WHO
About Filing a Complaint ALLEGEDLY VIOLATED THE HATCH ACT (Subject)
Biographical Information * Denotes Required Fields

Information about Subject Subject’s Employment Status:*

Alleged Violation Federal government employee
Other Actions (State or Local government employee
| Attachments (Private, Nonprofit organization employee
Consent Title:
[Certification —
} — — Subject's First Name:* Subject’s Middle Initial:

Submission SSS —
a Subject's Last Name:*

| Department name:*

| Agency:*

Position Title:

Subject's Address* [¥] Domestic [[] International
Address Line 1*

Address Line 2

City* State”
Zip Code*

Office Telephone: Ext.

Home Telephone: Other Telephone:

Email Address:

Does the Subject have knowledge of the Hatch Act?:*
(Yes [JNo  [jUnsure

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 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.

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4 Add / Delete a Complaint SUBJECT’S SUPERVISOR’S INFORMATION

Subject's Supervisor's First Name:

Improper Politicat Activities
(Hatch Act)

Subject’s Supervisor's Last Name:

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 PART 4: ALLEGED VIOLATION
Submission * Denotes Required Fields

1. For complaints involving a Subject employed by the federal government, which of the

following actions are you alleging?*

(LJ Using one’s official authority or influence for the purpose of interfering with or
affecting the result of an election.

Soliciting, accepting, or receiving political contributions.

(Being a candidate in a partisan election.

LJ Soliciting or discouraging the participation in political activity of any person who
has business before their employing agency.

LJ Engaging in political activity while on duty, in any room or building occupied in the

discharge of official duties, while wearirig a uniform or official insignia, or while
using a vehicle owned or leased by the United States government.

U1 Taking an active part in political management or political campaigns (This

| prohibition applies only to further restricted employees. A list of such employees
| can be found here or at 5 U.S.C. § 7323(b)).

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.

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

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