OSC Form 13

U.S. OFFICE OF SPECIAL COUNSEL
Form OSC-13 (09-12)

(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 complaint form can 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 not required
that this complaint form be used, use of this form will be helpful to OSC in expediting the processing
and investigating of complaints. Please complete the information requested below as fully and
accurately as possible.
SEND COMPLETED COMPLAINT FORMS TO:

By Mail:

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

By Fax:

(202) 254-3700
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)
Page 3 of 7

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 FOLLOWING ONLY IF THE SUBJECT IS A STATE OR LOCAL 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 complai nt 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 che ck, if filing el ectronically) 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 u se 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 represe ntative will c ontact yo u, explain the circumstances, and provid e 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 whi ch OSC can use or disclose information unde r 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 6, 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 compl aint, 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, wi thout disclosing my name or other ide ntifying information, if OS C 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 6, 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 comp laint. 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 in formation from my
complaint file when permitted by the Privacy Act (including circumstances summarized in Part 6, below).
___________________________________________________
Complainant's Signature for Consent Statement 3

_______________________________
Date Signed

COMPLAINT OF POSSIBLE PROHIBITED POLITICAL ACTIVITY (HATCH ACT VIOLATION)
Page 6 of 7

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 Of fice 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;

PART 6: PRIVACY ACT / PAPERWORK REDUCTION ACT STATEMENTS

Privacy Act and Routine Uses. Limited disclosure of information from OSC files is needed to fulfill OSC's investigative,
prosecutorial, and related responsibilities. OSC has described 27 routine uses (“a” through “aa”) for information in its
files in the Federal Register (F.R.), at 77 F.R. 24242 (April 23, 2012). A copy of the routine uses is available from OSC
upon request. A summary of the routine uses appears below. 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 or whistleblower permitting the
disclosure.
OSC may disclose information from its files in the following circumstances to:
a. disclose that an allegation of prohibited personnel practices or other prohibited activity has been filed;
b. 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;
c. disclose information about allegations or complaints of discrimination to entities concerned with enforcement of
antidiscrimination laws;
d. the Merit Systems Protection Board (MSPB) or the President, when seeking disciplinary action;
e. 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;
f. disclose information to Congress in OSC's annual report;
g. disclose information to third parties as needed to conduct an investigation; resolve an allegation; or to give notice of
the status or outcome of an investigation; and to an agency, Office of Inspector General (OIG), complainant
(whistleblower), the President, Congressional Committees, or the National Security Advisor regarding disclosures under
5 U.S.C. 1213; or to give notice of the status or outcome of a review;
h. disclose information as needed to obtain information about hiring or retention of an employee; issuance of a security
clearance; classification of a job; conduct of a security or suitability investigation; award of a contract; or issuance of a
license, grant, or other benefit;
i. the Office of Management and Budget (OMB) for certain legislative coordination and clearance
purposes;
j. provide information from an individual's record to a congressional office acting pursuant to the
individual's request;
k. furnish information to the National Archives and Records Administration for records management
purposes;
l. produce summary statistics and workforce or other studies;
m. provide information to the Department of Justice (DOJ) as needed for certain litigation purposes;
n. provide information to courts or adjudicative bodies as needed for certain litigation purposes;
o. disclose information to the MSPB as needed in special studies authorized by law;
p. coordinate with an agency's OIG or comparable entity, to facilitate the coordination and conduct of investigations and
review of allegations, including notification of the disposition of matters referred to OSC by that office;
q. 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);

r. the Department of Labor and others as needed to implement the Uniformed Services Employment
and Reemployment Rights Act of 1994 (USERRA), as amended, including demonstration projects, and the Veterans’
Employment Opportunities Act of 1998, or disclose information to the Department of Defense, Employer Support of the
Guard and Reserve for mediation;
s. disclose records, when OSC has agreed to represent a USERRA complainant, from the corresponding investigative
file to the relevant litigation file, and from the litigation file to the complainant;
t. disclose information to agency contractors, or other non-OSC employees performing or working on a contract, service,
or other activity as needed to accomplish an agency function;
u. make lists and reports available to the public pursuant to 5 U.S.C. 1219;
v. disclose information as needed to appropriate agencies, entities, and persons in the event of a confirmed or
suspected data breach to respond to and prevent, minimize, or remedy harm;
w. disclose information to appropriate federal entities with subject matter expertise as needed to obtain advice on any
authorities, programs, or functions associated with records in this system;
x. disclose information to appropriate law enforcement entities where OSC becomes aware of a violation or potential
violation of civil or criminal law or regulation; and to OPM and OMB pursuant to 5 U.S.C. 1214;
y. disclose information, when necessary, to the Integrity Committee established under the Inspector General Act, and
under section 7(b) of Public Law 110-409;
z. disclose information to the DOJ and/or the Federal Bureau of Investigation, as required, for inclusion in the National
Instant Criminal Background Check System; and
aa. disclose information to another Federal entity, as needed, under the Freedom of Information Act or the Privacy Act.

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.