osc13.7.30.09

U.S. OFFICE OF SPECIAL COUNSEL
Form OSC-13 (03-05)

(202) 254-3650 / (800) 854-2824
OMB Control No. 3255-0002

COMPLAINT OF POSSIBLE PROHIBITED POLITICAL ACTIVITY
(VIOLATION OF THE HATCH ACT)

INFORMATION ABOUT FILING A COMPLAINT WITH OSC

This compla int form c an be used to file complaint s alleging violations of the Hatch Act by federal,
District of Columbia, state and local and nonprofit organization employees. While it is no t required
that this complaint form be used, use of this form will be helpful to OSC in expediting the processing
and in vestigating of co mplaints. Please compl ete th e info rmation req uested belo w as fully a nd
accurately as possible.
SEND COMPLETED COMPLAINT FORMS TO:

By Mail: Hat

ch Act Unit
Office of Special Counsel
1730 M Street, N.W. (Suite 218)
Washington, DC 20036-4505

By Fax: (202

) 54-3700
Electronically:

WWW.OSC.GOV (AT “FILE COMPLAINTS ONLINE”)

PLEASE KEEP A COPY OF YOUR COMPLAINT, ANY SUPPORTING DOCUMENTATION, AND ANY ADDITIONAL
ALLEGATIONS SENT IN WRITING 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.

INFORMATION ABOUT THE HATCH ACT
The Hatch Act prohibits federal, District of Columbia, some state and local and nonprofit organization employees from
engaging in certain types of political activities. See 5 U.S.C. §§ 7321- 7326 and 5 U.S.C. §§ 1501-1508.
Federal Employees are generally prohibited from:
1. Using their official authority or influence for the purpose of interfering with or affecting the result of an election.
2. Soliciting, accepting, or receiving political contributions (with some exceptions).
3. Running for nomination or as candidates for partisan political office.
4. Soliciting or discouraging the participation in political activity of any person who has business before their
employing agency.
5. Engaging in political activity while on duty, in any room or building occupied in the discharge of official duties,
while wearing a uniform or official insignia, or while using a vehicle owned or leased by the United States
government.
State and Local Employees are prohibited from*:
1. Using their official authority or influence for the purpose of interfering with or affecting the result of an election
or a nomination for office.
2. 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.
3. Being a candidate for partisan political office.

* Employees of some private, nonprofit organizations are subject to the same restrictions on political activity that apply to covered state and local employees.
VISIT WWW.OSC.GOV
FOR MORE INFORMATION ABOUT THE HATCH ACT

COMPLAINT OF POSSIBLE PROHIBITED POLITICAL ACTIVITY (HATCH ACT VIOLATION)
Page 2 of 7

U.S. OFFICE OF SPECIAL COUNSEL

(202) 254-3650 / (800) 854-2824

COMPLAINT OF POSSIBLE PROHIBITED POLITICAL ACTIVITY
(VIOLATION OF THE HATCH ACT)
(Please print legibly or type and complete all pertinent items. Enter "N/A" (Not Applicable) or "Unknown" where appropriate.
(If more space is needed, use Continuation Sheet at page 4.)

PART 1: COMPLAINANT’S INFORMATION
1. Name of person filing complaint:

Mr. (

)

Ms. (

)

Mrs. (

)

Miss (

)

______________________________________________________________________________________
2. Agency name (if referring complaint): ________________________________________________________
3. Agency address (if referring complaint): ______________________________________________________
4. Home or mailing address (if filing complaint): __________________________________________________
______________________________________________________________________________________
5. Contact information:

Telephone number(s):
Fax number:
E-mail address:

6.

(
) ___________________ (Home)
(
) ___________________ (Office) Ext. ______
(
) ___________________
____________________________________________

How did you first become aware that you could file a complaint with OSC?
(
(
(

) OSC Web site
( ) OSC speaker
( ) OSC brochure
( ) OSC poster
) news story
( ) agency personnel office ( ) union
( ) co-worker
) other (please describe): ____________________________________________________________
Date (approximate): ___________________________________________
PART 2: SUBJECT’S INFORMATION
PARTPART 1: PROHIBITED POLITICAL ACTIVITY (GENERAL)

7.

Name of person who violated the Hatch Act (“Subject”): _________________________________________

8.

Agency: ______________________________________________________________________________

9.

Position/Title: __________________________________________________________________________

10. Federal, District of Columbia (DC), State/Local or Nonprofit employee (check one):
(
) Federal employee
(
) DC employee
(
) State or Local employee
(
) Nonprofit organization employee
11. Contact information:

Telephone number(s):
Fax number:
E-mail address:

(
) ___________________ (Home)
(
) ___________________ (Office) Ext. ______
(
) ___________________
____________________________________________

COMPLAINT OF POSSIBLE PROHIBITED POLITICAL ACTIVITY (HATCH ACT VIOLATION)
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12. Subject’s Supervisor’s Name: ____________________________________________________________
13. Subject’s Supervisor’s Contact information:
Telephone number(s):

Fax number:
E-mail address:
14. Does Subject have knowledge of the Hatch Act? (check one):

(
(

) ________________ (Home)
) ________________ (Office) Ext.
_________________________
(
) __________________________
__________________________________
(
(
(

) Yes
) No
) Not sure

15. If you answered Yes to question 14, please explain how Subject knows about the Hatch Act (e.g. agency
training, agency’s distribution of brochures, flyers, e-mails, etc.) __________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
PLEASE COMPLETE THE FOLL OWING ONLY IF THE SUBJECT IS A STATE OR LOCA L OR NONPROFIT
ORGANIZATION EMPLOYEE. IF NOT, SKIP TO PART 3:
16. Does Subject’s employing agency receive federal funds? (check one): (

) Yes

(

) No

(

) Not sure

17. If you answered Yes to question 16, please provide the following:
a) Nature and source of federal funds ______________________________________________
_________________________________________________________________________
_________________________________________________________________________
b) Name of individual (s) at agency responsible for federal funds: _____________________
_________________________________________________________________________
c) Contact information for individual (s) responsible for federal funds:
Telephone Number (s): (

) _________________________________________________

Fax Number:

) _________________________________________________

(

E-mail address: ____________________________________________________________

18. Does the Subject perform duties in connection with federal funds? (check one)

(

) Yes

(

) No

(

) Not sure

19. If you answered yes to question 18, please provide the type of duties Subject performs in connection with
Federal funds:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

COMPLAINT OF POSSIBLE PROHIBITED POLITICAL ACTIVITY (HATCH ACT VIOLATION)
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PART 3: DETAILS OF COMPLAINT
20. What are the actions that you are reporting to OSC? Please attach all supporting documentation to the
complaint form. IF YOU ARE ALLEGING CANDIDACY IN A PARTISAN ELECTION, PLEASE PROVIDE
THE DATE OF THE ELECTION AND/OR THE DATE NOMINATING PETITIONS ARE DUE. IF YOU ARE
ALLEGING POLITICAL ACTIVITY WHILE ON DUTY OR IN A FEDERAL BUILDING FOR FEDERAL
EMPLOYEES, PLEASE PROVIDE THE TIME AND/OR PLACE THE ACTIVITY OCCURRED.
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_______________________________________________________________________________
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_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

COMPLAINT OF POSSIBLE PROHIBITED POLITICAL ACTIVITY (HATCH ACT VIOLATION)
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PART 4: CONSENT TO CERTAIN DISCLOSURES OF INFORMATION
OSC asks everyone who files a complaint alleging a possible prohibited political activity (violation of the Hatch
Act) to select one of three Consent Statements shown below. IF YOU DO NOT SELECT ONE OF THE THREE
CONSENT STATEMENTS BELOW, OSC WILL ASSUME THAT YOU HAVE SELECTED CONSENT
STATEMENT 1. Please: (a) select and sign (or check, if filing electronically) one of the Consent Statements
below; and (b) keep a copy of the Consent Statement you select (as well as a copy of all documents that you
send to OSC) for your own records.
If you initially select a Consent Statement that restricts OSC's use of information, you may later select a less
restrictive Consent Statement. If your selection of Consent Statement 2 or 3 prevents OSC from being able to
conduct an investigation, an OSC representative will contact you, explain the circumstances, and provide you
with an opportunity to select a less restrictive Consent Statement.
You should be aware that the Privacy Act allows information in OSC case files to be used or disclosed for certain
purposes, regardless of which Consent Statement you sign. See 5 U.S.C. § 552a(b). Information about certain
circumstances under which OSC can use or disclose information under the Privacy Act appears on the next
page.
(Please sign one)
Consent Statement 1
I consent to OSC’s communication with the pertinent individuals involved in my complaint. I agree to allow OSC
to disclose my identity as the complainant, and information from or about me, if OSC decides that such
disclosure is needed to investigate the allegation(s) in my complaint. I understand that regardless of the
Consent Statement I choose, OSC may disclose information from my complaint file when permitted by the
Privacy Act (including circumstances summarized in Part 5, below).
___________________________________________________
Complainant's Signature for Consent Statement 1

_______________________________
Date Signed

Consent Statement 2
I consent to OSC’s communication with the pertinent individuals involved in my complaint, but I do not agree to
allow OSC to disclose my identity as the complainant. I agree to allow OSC to disclose only information from or
about me, without disclosing my name or other identifying information, if OSC decides that such disclosure is
needed to investigate the allegation(s) in my complaint. I understand that in some circumstances OSC could not
maintain my anonymity while communicating with the pertinent individuals. In such cases, I understand that this
request for confidentiality might prevent OSC from taking further action on my complaint. I also understand that
regardless of the Consent Statement I choose, OSC may disclose information from my complaint file when
permitted by the Privacy Act (including circumstances summarized in Part 5, below).
___________________________________________________
Complainant's Signature for Consent Statement 2

_______________________________
Date Signed

Consent Statement 3
I do not consent to OSC’s communication with the pertinent individuals involved in my complaint. I understand
that if OSC decides that it cannot investigate the allegation(s) in my complaint without communicating with these
individuals, my lack of consent will probably prevent OSC from taking further action on the complaint. I
understand that regardless of the Consent Statement I choose, OSC may disclose information from my
complaint file when permitted by the Privacy Act (including circumstances summarized in Part 5, below).
___________________________________________________
Complainant's Signature for Consent Statement 3

_______________________________
Date Signed

COMPLAINT OF POSSIBLE PROHIBITED POLITICAL ACTIVITY (HATCH ACT VIOLATION)
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PART 5: CERTIFICATION AND SIGNATURE
I certify that all of the statements made in this complaint (including any continuation pages) are true,
complete, and correct to the best of my knowledge and belief. I understand that a false statement or
concealment of a material fact is a criminal offense punishable by a fine of up to $250,000, imprisonment
for up to five years, or both. 18 U.S.C. § 1001.
___________________________________________________
Signature

_______________________________
Date Signed

PART 6: PRIVACY ACT / PAPERWORK REDUCTION ACT STATEMENTS

Routine Uses. Limited disclosure of information from OSC files is needed to fulfill OSC's investigative,
prosecutorial, and related responsibilities. OSC has described 18 routine uses for information in its files in the
Federal Register (F.R.), at 66 F.R. 36611 (July 12, 2001), and 66 F.R. 51095 (October 5, 2001). A copy of the
routine uses is available from OSC upon request. A summary of the routine uses appears below.
OSC may disclose information from its files in the following circumstances:
1. to disclose that an allegation of prohibited personnel practices or other prohibited activity has been filed;
2. to disclose information to the Office of Personnel Management (OPM) as needed for inquiries involving
civil service laws, rules or regulations, or to obtain an advisory opinion;
3. to disclose information about allegations or complaints of discrimination to entities concerned with
enforcement of antidiscrimination laws;
4. to the MSPB or the President, when seeking disciplinary action;
5. to the involved agency, MSPB, OPM, or the President when OSC has reason to believe that a prohibited
personnel practice has occurred, exists, or is to be taken;
6. to disclose information to Congress in OSC's annual report;
7. to disclose information to third parties as needed to conduct an investigation; obtain an agency
investigation and report on information disclosed to OSC's whistleblower disclosure channel; or to give
notice of the status or outcome of an investigation;
8. to disclose information as needed to obtain information about hiring or retention of an employee;
issuance of a security clearance; conduct of a security or suitability investigation; award of a contract; or
issuance of a license, grant, or other benefit;
9. to the Office of Management and Budget (OMB) for certain legislative coordination and clearance
purposes;

COMPLAINT OF POSSIBLE PROHIBITED POLITICAL ACTIVITY (HATCH ACT VIOLATION)
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10. to provide information from an individual's record to a congressional office acting pursuant to the
individual's request;
11. to furnish information to the National Archives and Records Administration for records management
purposes;
12. to produce summary statistics and work force or other studies;
13. to provide information to the Department of Justice as needed for certain litigation purposes;
14. to provide information to courts or adjudicative bodies as needed for certain litigation purposes;
15. to disclose information to the MSPB as needed in special studies authorized by law;
16. for coordination with an agency's Office of Inspector General or comparable entity, to facilitate the
coordination and conduct of investigations and review of allegations;
17. to news media or the public in certain circumstances (except when the Special Counsel determines that
disclosure in a particular case would be an unwarranted invasion of personal privacy); and
18. to the Department of Labor and others as needed to implement the Uniformed Services Employment
and Reemployment Rights Act of 1994, and the Veterans’ Employment Opportunities Act of 1998.
If OSC officials believe that disclosure may be appropriate in a situation not covered by one of OSC's routine
uses, or one of the 11 other exceptions to the Privacy Act's general prohibition on disclosure, OSC will seek
written authorization from the complainant permitting the disclosure.
Purposes, Burdens, and Other Information. An agency may not conduct or sponsor a collection of information,
and persons may not be required to respond to a collection of information, unless it: (a) has been approved by
OMB; and (b) displays a currently valid OMB control number. The information in this form is collected pursuant
to OSC's legal responsibility to investigate: (a) allegations of prohibited political activity (5 U.S.C. § 1216). The
information will be reviewed by OSC to determine whether the facts establish its jurisdiction over the subject of
the complaint, and whether further investigation and disciplinary action is warranted. The reporting burden for
this collection of information is estimated to be an average of 30 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering the data needed, and completing and
reviewing the form. Please send any comments about this burden estimate, and suggestions for reducing the
burden, to the Office of Special Counsel, Legal Counsel and Policy Division, 1730 M Street, N.W. (Suite 218),
Washington, DC 20036-4505.