DOT Form 1050-10 Final Agency Decision Request Form

OMB No: 2105-0556

Expiration Date: MM/DD/YYYY

Public Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number.  The OMB Control Number for this information collection is 2105-0556.  Public reporting for this collection of information is estimated to be approximately 2.5 hours per respondent, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information.  All responses to this collection of information are voluntary.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, U.S. Department of Transportation, Room W56-440, 1200 New Jersey Ave, SE, Washington, D.C. 20590.

Privacy Act Statement

The Privacy Act requires that we provide you with the following information regarding our use of your Personally Identifiable Information. The information on this form is solicited under the authority of 29 C.F.R. Part 1614. The purpose of this form is to inform Complainants about the EEO complaint process. Information provided on this form will be used by the Department of Transportation to determine whether the complaint was timely filed, whether the claims in the complaint are within the purview of 29 C.F.R. Part 1614, to provide a factual basis for investigation of the complaint, and to ensure that the proper processes were followed. Formal complaints of employment discrimination must be in writing, signed by the Complainant (or attorney representative), and must identify the parties and action or policy at issue. Failure to comply may result in the Department of Transportation dismissing the complaint. It is not mandatory that this form be used to provide the requested information.

FINAL AGENCY DECISION REQUEST FORM**

Dear Sir/Madam:

I am requesting a final decision by the Department of Transportation in accordance with 29 C.F.R. § 1614.108 (g). I hereby certify that either more than 180 days have passed from the date I filed my complaint or I have received a notice from the agency that I have thirty (30) days to elect a hearing or a final agency decision.

My Name: ___________________________________

Address: ___________________________________

___________________________________

Agency Name: U.S. Department of Transportation

Address: 1200 New Jersey Avenue, S.E. W76-401

Washington, DC 20590

Agency No. __________________________________

Signed: __________________________________________ Date: ______________________

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** Request for Final Agency Decision By E-mail.

In lieu of submitting this form, you may submit your request for a final agency decision by email to “[email protected].” Your request must be received within thirty (30) calendar days of your receipt of this letter. The Subject line must contain the phrase “Final Agency Decision Request.” Please only use one method (electronic or hardcopy) to submit your request. If you do not receive a confirmation email within two (2) business days, please call 202-366-2206.