Form VETS-1010 VETS/USERRA/VP Form 1010

Eligibility Data Form: Uniformed Services Employment and Reemployment Rights Act and Veterans' Preference

vets-1010-Form-130724

Eligibility Data Form: Uniformed Services Employment and Reemployment Rights Act and Veterans' Preference

OMB: 1293-0002

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OMB NO. 1293-0002 (EXP xx/xx/201x) VETS/USERRA/VP Form 1010 (REV xx/2013)


ELIGIBILITY DATA FORM: For claims under the Uniformed Services Employment and Reemployment Rights Act (USERRA)

and/or claims under the Veterans’ Preference (VP) provisions of the Veterans Employment Opportunities Act of 1998

U.S. Department of Labor, Veterans’ Employment and Training Service


Mail (or FAX) to:


Veterans' Employment and Training Service Phone: (866) 4-USA-DOL ((866)-487-2365))

U.S. Department of Labor FAX: (404) 562-2313

ATTENTION: Form 1010

61 Forsyth Street, S.W., Room 6T85

Atlanta, Georgia 30303


Shape1 PLEASE TYPE OR PRINT


Section I: Claimant Information


1. Name:



Last Name First Name M.I.


2. Address:


Street City State ZIP


Shape4 Shape5 3. Social Security No:

4. Home Phone:

5. Cell Phone:



Shape6 6. Email Address:

7. Do you have a military service-connected disability? Yes No



Section II: Uniformed Service Information

Shape8 Shape7 Shape19 Shape14 Shape11 Shape10 Shape18 Shape13 Shape16 Shape12 Shape15 Shape9 Shape17



8. Serve(d) In: Air National Guard Army National Guard Army Reserve Air Force Reserve Naval Reserve

Shape20 Shape21

Marine Corps Reserve Coast Guard Reserve Army Air Force Navy Marine Corps Coast Guard

Public Health Service Other (Explain in “Comments”) None (Retaliation Claim – Explain in “Comments”)

9. If Reserve/National Guard:


(a) Name of Unit:


(b) Unit Address:


(c) Unit Phone:


10. Dates of Service (If applicable): (a) From:

To:


OR (b) Date of Examination/Rejection for Service:


Shape22 Shape23 Shape24 Shape25 Shape26 11. Type of Discharge or Separation: Honorable Conditions Entry Level Uncharacterized Medical Other than Honorable

Shape27 Shape28 Other (Explain in “Comments”) Not Applicable




Section III: Employer Information


12. Employer or Prospective Employer’s Name:


13. Address:


Street City State ZIP


14. Principal Employer Contact (PEC):

(a) PEC Name/Title:


(b) PEC Phone:


15. Employment Dates (If applicable): From:

To:

Shape30

Shape31 Shape32 16. Since beginning work with this employer, has your cumulative uniformed service exceeded 5 years? Yes No

If YES, explain in Comments box at end of this claim form.


17. Name of Union(s) That Represent You:


18. Title of the Position or Occupation that is related to your claim (the job that you either now hold, or used to hold, or applied for, with this employer):

Section IV: Claim Information


Shape34 Shape35 19. Was the Employer Support of the Guard and Reserve (ESGR) involved in handling your claim initially? Yes No

Use items #20 and #21 to identify the program(s). (NOTE: Most claims – but not all – apply to only one program.)

  • For this claim to apply only to Veterans’ Preference (VP) in Federal Employment: Complete item #20, and skip #21.

  • For this claim to apply only to USERRA: …………………………………………….. Skip item #20, and complete #21.

    Shape36 Shape37

  • For this claim to apply to both VP and USERRA: …………………………………… Complete both items #20 and #21.

20. Veterans’ Preference Issue (Check One): Hiring Reduction-in-Force (RIF)

Shape39 Shape38 Shape40


Shape43 Shape41 Shape42

21. USERRA Issue(s): Military Obligations Discrimination Reinstatement Initial Hiring Discrimination

Shape50 Shape49 Shape46 Shape48 Shape45 Shape44 Shape47

Discrimination as Retaliation for any Action Status Pay Rate Seniority Other Non-Seniority Benefits

Shape51 Shape53 Shape54 Shape52

Pension Layoff Promotion Vacation Health Benefits Special Protected Period Discharge

Reasonable Accommodations/Retraining for Disabled Reasonable Accommodations/Retraining for Non-Qualified/Non-Disabled Other



If Claim Concerns Hiring, Promotion, RIF or Termination


22. Title of Position Held or Applied For:


23. Pay Rate:


24. Date of Application Employment/Promotion:


(a) Vacancy Announcement Number:


(b) Date Vacancy Opened:

(c) Date Vacancy Closed: _


If Claim Concerns Reemployment Following Service


Shape55 Shape56 25. Was Prior Notice of Service Provided to Employer? Yes No (If “No,” Explain in Comments)


Shape57 Shape58 26. (a) Who Provided Notice of Service to Employer? Self Other (name):


Shape59 Shape60 Shape61 (b) Was the Notice of Service: Written Oral Both


(c) Date Notice of Service was given to Employer:


27. Name/Title of Person to Whom Notice of Service was Provided:


28. Date Applied for Reemployment: OR Date Returned to Work:


29. Reemployment Application Made To: Name:

Title:


Shape62 Shape63 30. Reemployed or Reinstated? Yes (date): No


(a) If YES, what position?

at what pay rate?


(b) If NO, Date denied:

Reason(s) given:


(c) Who denied (Name and Title):



Shape64 PUNISHMENT FOR UNLAWFUL STATEMENTS

The information provided in this complaint will be utilized by the U.S. Department of Labor, Veterans’ Employment and Training Service (VETS) to initiate an investigation of alleged violations of the Uniformed Services Employment and Reemployment Rights Act (USERRA) Title 38, U.S.C., Sections 4301-4335; and/or the Veterans Preference (VP), provisions of

the Veterans Employment Opportunities Act of 1998 (VEOA), 5 U.S.C. §3330a-3330c. Potential claimants should keep in mind that it is unlawful to knowingly and willfully make any “materially false, fictitious, or fraudulent statements or representation” to a federal agency. Violations can be punished under Section 2 of the False Statements Accountability Act of 1996 by a fine and/or imprisonment of not more than 5 years. 18 U.S.C. § 1001.


I certify that the above information is true and correct to the best of my knowledge and belief. I authorize the U.S. Department of Labor to contact my employer or any other person for information concerning this claim. I further authorize my employer or any other person to release such information to the U.S. Department of Labor. Pursuant to 5 U.S.C., Section

552a(b) of the Privacy Act, I authorize the U.S. Department of Labor and the U.S. Department of Defense to release information and records necessary for the investigation and prosecution of my claim.


SIGNATURE:


DATE:

Shape65

Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Veterans Employment and Training Service, Room-S1316, 200 Constitution Avenue, N.W., Washington, DC 20210.


NOTIFICATION OF USERRA CLAIMANT’S RIGHTS

For claims arising under USERRA, a person has a right to commence an action for relief directly against the employer in the appropriate federal district court (in the case of a complaint against a State or private employer), pursuant to 38 U.S.C. § 4323(a)(3), or the Merit Systems Protection Board (in the case of a complaint against a Federal executive agency or the

Office of Personnel Management), pursuant to 38 U.S.C. § 4324(b).


PRIVACY ACT STATEMENT

The primary use of this information is by staff of the Veterans Employment and Training Service in investigating cases under USERRA or laws/regulations relating to veterans

preference in Federal employment. Disclosure of this information may be made to: a Federal, state or local agency for appropriate reasons; in connection with litigation; and to an individual or contractor performing a Federal function. Furnishing the information on this form, including your Social Security Number, is voluntary. However, failure to provide this

information may jeopardize the Department of Labors ability to provide assistance on your claim.

Continue in Comments box &/or use additional sheet(s) to explain items if needed – Sign and date form (above)

OMB NO. 1293-0002 (EXP 10/31/2016) VETS/USERRA/VP Form 1010 (REV 4/2013) Page 2

Explain your claim in detail – List all remedies you seek

Shape66 Use additional sheet(s) if needed – Initial & date each page at bottom



Comments:






















































Mail (or FAX) to:

INITIALS: DATE:

Shape67

Veterans' Employment and Training Service Phone: (866) 4-USA-DOL ((866)-487-2365))

U.S. Department of Labor FAX: (404) 562-2313

ATTENTION: Form 1010

61 Forsyth Street, S.W., Room 6T85

Atlanta, Georgia 30303

OMB NO. 1293-0002 (EXP 10/31/2016) VETS/USERRA/VP Form 1010 (REV 4/2013) Page 3

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleU.S. DOL VETS Form 1010 - OMB No. 1293-0002
AuthorU.S.Deptof Labor/ELAWS
File Modified0000-00-00
File Created2021-01-29

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