Current SSA-437

COMPLAINT FORM FOR ALLEGATIONS OF PROGRAM
DISCRIMINATION BY THE SOCIAL SECURITY ADMINISTRATION
PURPOSE: The purpose of this form is to assist you in filing a discrimination complaint about a
program or activity conducted by the Social Security Administration (SSA). If you need any help filling
out this form, you may call us at (866) 574-0374. You are not required to use the complaint form; you
may write a letter instead. If you write a letter, it must contain all of the information requested by this
form and it must be signed by you or your authorized representative. Incomplete information or an
unsigned complaint form will delay the processing of your complaint.
SSA POLICY: SSA policy requires us to conduct our programs and activities in a way that does not
discriminate on the basis of: race; color; national origin (including limited English proficiency); religion;
sex (including sexual orientation and gender identity); disability; age; or parental status. No SSA
officer, employee, or agent may intimidate, threaten, harass, coerce, discriminate, or otherwise
retaliate against anyone who has filed a complaint of alleged discrimination or who has participated in
any manner in an investigation or other proceeding raising allegations of discrimination.
COMPLAINTS ABOUT EMPLOYMENT WITH SSA: If your complaint of discrimination concerns
employment with SSA, you should not use this form. You must contact an SSA Equal Employment
Opportunity (EEO) Counselor within 45 days of the action you believe was based on discrimination.
To reach an EEO Counselor, you can call SSA’s Office of Civil Rights and Equal Opportunity on the
following toll-free number – (866) 744-0374
COMPLAINTS ABOUT DECISIONS ON CLAIMS FOR PROGRAM BENEFITS: If your complaint of
discrimination concerns a decision that we made on a claim for benefits under one of the benefit
programs SSA administers, and if the relief you are seeking is that SSA change this decision, YOU
SHOULD NOT USE THIS FORM. You must appeal the decision according to the procedures and
within the timeframes described in the notice of appeal rights you received with our decision.
If you believe that your claim for benefits was decided because of discrimination, you must say
this in the appeal, and include the facts on which you base this allegation.
COMPLAINT ABOUT ACTIONS TAKEN IN CONNECTION WITH THE PROCESSING OF A CLAIM
FOR BENEFITS: If you believe that an SSA employee or adjudicator who was involved in processing
your claim for benefits was biased or prejudiced against you, and that the action the employee took on
your claim was based on discrimination and not on the facts of your case, you may file a complaint of
program discrimination using this form. If your complaint is complete, timely and within our jurisdiction,
we will investigate and decide it. However, the decision we make on a complaint of program
discrimination does not change the action that was taken on a claim for benefits. The only way to get
the decision on a claim for benefits changed is to file an appeal of that decision

Form SSA-437-BK (11-2009) EF (11-2009)

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FILING DEADLINE: This form or your written complaint of discrimination must be filed within 180
days of the action you allege was based on discrimination. If the action took place more than 180 days
ago, you must explain why you waited to file the complaint. SSA will waive the 180-day requirement in
cases where we believe there was good cause (extenuating circumstances) for the late filing.
If you disagree with an action SSA took on a claim for benefits and our program rules require you to
appeal the action within a specific time period, you must file that appeal to change the decision on your
claim for benefits. Filing a complaint of discrimination about the merits of your claim for benefits will
not extend the time for filing an appeal.
HOW AND WHERE TO FILE: To file a complaint of discrimination, please complete and send a
signed and dated copy of the discrimination complaint form or a signed and dated letter containing the
information requested in the form to:
Social Security Administration
Program Discrimination Complaint Adjudication Office
Room 617 Altmeyer Building
6401 Security Boulevard
Baltimore, MD 21235
If you prefer, you can send your complaint to us by fax or email. The number to which you can fax a
complaint is: (410) 597-0507.
If you send us your complaint by email, you must attach a copy of the signed and dated complaint form
or letter of complaint to your email, and you should only send the email to us at the following address:
[email protected]. If you email your complaint to any other email address, it could
compromise the privacy and security of the information you are sending us about your complaint.
If you have any questions about the complaint process, or if you have questions about a complaint you
have already filed, you may use the above contact information to write, fax or email us, or you may call
us toll-free at (866) 574-0374.

Form SSA-437-BK (11-2009) EF (11-2009)

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Form Approved
OMB No. 0960-0585

Social Security Administration
Program Discrimination Complaint Form
1.

State your name, address and Social Security number.
Name
Address
City

State

ZIP

State

ZIP

Daytime phone number where you can be reached
Social Security Number
2.

Person(s) allegedly discriminated against (if
different from person identified in question 1):
Address
City
Daytime phone number(s) where person(s) can be
reached.

3.

Please explain your relationship to any person(s) identified in question 2: _____________

4.

It is against SSA policy for a program conducted by SSA to discriminate against you based on
any of the following reasons: race; color; national origin (including limited English proficiency);
religion; sex (including sexual orientation and gender identity); disability; age; and parental
status. (Note: Not all bases apply to all of SSA's programs.) It also is against SSA policy to
retaliate against you because you filed a discrimination complaint or to retaliate against anyone
who assisted you in filing a complaint. Please specify the basis or bases on which you believe
you were discriminated against.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

5.

On what date(s) did the alleged discrimination take place?

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6.

Complaints must generally be filed within 180 days of the alleged discrimination. If the date of
discrimination listed above is more than 180 days ago, you may request a waiver of the time
limit for filing a complaint. If you wish to request a waiver, please explain why you waited until
now to file your complaint.

7.

Please describe the action SSA took that you believe was based on discrimination or the SSA
policy, procedure, or practice that you believe is discriminatory. Explain why you believe you
were discriminated against. Identify any people you allege are treated differently than you
because of discrimination. Give the name(s) of anyone involved and describe what they did. If
the action happened in an SSA office, give the office’s address (street, city, State). If the action
happened during a phone call with SSA, give the number you called or were called from, whom
you talked to, and the date and time of the call. You may use additional sheets if necessary.
You may also attach copies of any documents that will help us understand what happened.

8.

If you believe that you were retaliated against for filing or participating in a prior discrimination
complaint, please explain the circumstances below. Be sure to explain how you were retaliated
against and describe what actions you took that you believe led to the retaliation.

Form SSA-437-BK
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9.

Please list the names, addresses, and phone numbers of any persons who may have
witnessed, or have additional information about, the action(s) that are the subject of your
complaint. If the person is an SSA employee, it is sufficient to give the employee’s name and
the name or location of the SSA office.
Name

Address

Phone Number

10.

Did you write to or talk with any SSA official(s) about the actions you believe to be
discrimination? If so, give the name of the person(s) you talked to, the address of
the person’s office (street, city, State) or the phone number you called, the date(s)
you talked, and describe what happened.

11.

What would you like SSA to do as a result of your complaint? What remedy or accommodation
are you seeking because of the discrimination you allege?

12.

Have you, or has the person allegedly discriminated against, filed a complaint about this matter
with any other agency or organization?
Yes
No

12A.

If yes, identify the name and location of the office(s) where the complaint was filed.

12B.

When was the complaint filed?
MM/DD/YYYY

13.

How did you learn that you could file this complaint?

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14.

We cannot accept a complaint if it has not been signed. Please sign and date this
complaint form below.

Signature

Date

You must sign and date the complaint. If you are filing the complaint for someone else, you must also get
that person to sign and date it. If you are not able to get that person to sign the complaint, please explain
why, and be sure to complete question #2, so that we are able to contact that person. If you send the
complaint to us by email, be sure to attach a signed copy of the complaint.
HOW TO FILE THIS COMPLAINT
Send a completed, signed, and dated copy of pages 3 through 6 of the Program Discrimination Complaint
form and any supporting documentation you want us to see to:
Mailing Address:

Social Security Administration
Program Discrimination Complaint Adjudication Office
Room 617 Altmeyer Building
6401 Security Boulevard
Baltimore, MD 21235

Email Address:

[email protected]

Fax Number:

(410) 597-0507

If you have any questions about the form or need assistance completing it, you can call us toll-free at :
(866) 574-0374

The remaining information on this form is optional. Failure to answer these voluntary
questions will not affect SSA's decision to process your complaint.
Do you need special accommodations for us to communicate with you about this complaint? (Check all that apply)
Braille

Large Print

CD with Word file

Audio CD

Electronic mail

TDD

Sign language interpreter (specify language):
Foreign language interpreter (specify language):

Other (specify)

To help us better serve the public, please provide the following information for the person you believe was discriminated against
(you or the person on whose behalf you are filing).
ETHNICITY (select one)

RACE (select all that apply)

Hispanic or Latino

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Not Hispanic or Latino

Black or African American

White

Other (specify):

Preferred Language (if other
than English: _____________

Form SSA-437-BK
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Privacy Act Statement
Collection and Use of Personal Information
Complainants and individuals who cooperate in an investigation by the Social Security Administration
(SSA) into an allegation of discrimination are afforded certain rights and protections. This brief
description will provide you with an overview of these rights and protections.
SSA may collect information concerning complaints of program discrimination pursuant to 5 U.S.C.
§ 301, 29 U.S.C. § 794(a), 42 U.S.C. § 902(a)(5), 45 C.F.R. Part 85, 20 C.F.R. § 405.30, and Executive
Orders 13160 and 13166. The responses you provide will be used to make a decision on how we will
process your complaint. Your responses are voluntary; however, we may be unable to proceed with
processing your complaint if you choose not to provide the requested information. You do not have to
use this form. You may also write a letter that includes all of the requested information.
We rarely use the information you provide for any purpose other than for processing your complaint.
We may, however, disclose the information in accordance with routine uses of the Privacy Act (5 U.S.C.
§ 552a(b)), which include, but are not limited to, the following:
1. To a congressional office on behalf of an individual in response to an inquiry made at the request
of the individual who is the subject of the record;
2. To the Office of the President for the purpose of responding to an individual pursuant to an
inquiry from that individual or from an third party on the individual;
3. To another Federal agency or to a court or third party in litigation when the Government is a party
to a suit before the court;
4. To a Federal, State, or local agency for law enforcement purposes concerning a violation of law;
5. To the Department of Justice, the Equal Employment Opportunity Commission, or other Federal
and State agencies when necessary for the administration or enforcement of civil rights laws or
regulations
Complaint records are exempted as investigatory material, compiled for law enforcement purposes,
from certain Privacy Act access, amendment, correction, and notification requirements (5 U.S.C.
§ 552a(k)(2)). However, a complainant or any member of the public may request release of this
information under the provisions of the Freedom of Information Act (5 U.S.C. § 552).
A complete list of routine uses for this information is contained in our System of Records Notice 600275, Civil Rights Complaints Filed by Members of the Public. Additional information regarding this
form and our other system of records notices and Social Security programs are available from our
Internet website at www.socialsecurity.gov or at your local Social Security office.
The Paperwork Reduction Act--This information collection meets the requirements of 44 U.S.C.
§3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer
these questions unless we display a valid Office of Management and Budget control number. We
estimate that it will take about 1 hour to read the instructions, gather the facts, and answer the
questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address; do
not send the complaint form to this address.
Form SSA-437-BK
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