VETS-Form-1010a-20250327

OMB NO. 1293-0002 (XX/XX/XXXX)
VETS USERRA/VP/VEOA Form 1010(a) (REV XX/XXXX)

U.S. Department of Labor
Veterans' Employment and Training Service
USERRA/VP Claim Form Instructions
Questions 1a - 1c:
Questions 2a - 2e:
Questions 3 - 5:
Question 6:
Question 7 - 8:
Question 9:
Question 1:
Question 2:
Question 3a:
Question 3b:
Question 4:
Question 5a:
Question 5b:
Question 5c:
Question 6a:
Question 6b:
Questions 7a - 7e:
Questions 8a, 8b:
Question 8c:
Questions 9 - 10b:

Section A. Claimant Information Instructions

Self Explanatory
Enter the mailing address where you can be reached by an assigned investigator.
Enter the best email address and phone numbers where an investigator can reach you.
Enter your Social Security Number (SSN), or alternatively the last four digits of your SSN (e.g. 000-00-1234).
Self Explanatory
Select from the drop-down list whether your claim is for a USERRA or VP/VEOA potential violation.

Section B. Employer Information Instructions

Self Explanatory
Select "Yes" if the employer that potentially violated USERRA, VP, or VEOA is your current employer.
Enter the name of the employer who potentially violated USERRA, VP, or VEOA.
Select the type of employer from the drop-down list.
Self Explanatory
Enter in U.S. Dollars your base rate of pay, excluding overtime and bonuses.
Select from the drop-down list the type of pay period or pay basis for the pay rate entered in 5a.
Self Explanatory
Enter your date of employment with the employer that is the subject of your claim, if applicable.
If you weren't an employee of the employer that is the subject of your claim, enter the date of application or
interview.
Enter the mailing address of the employer, for the location where the potential violation occurred.
Enter the name and title of the person who an investigator should contact at the employer, concerning your claim.
Select from the drop-down list the type of representative identified in 8a, and 8b.
Enter the email address and phone numbers for the employer representative identified in 8a, and 8b.

Section C. USERRA Eligibility Information Instructions

General Instructions: Do not complete this section if your claim involves a potential violation of VP or VEOA.
Question 1: Select from the drop-down list the branch of service related to your claim. In most situations this will be the branch
of service where you were a member, applied to be a member, were obligated to perform service, or performed
service closest in time to the potential violation you are describing.
Question 2: Self Explanatory
Question 3: If "Yes" to 2, select from the drop-down list the Character of Service you received upon discharge or separation.
Questions 4a - 4b: If your claim is related to uniformed service that was performed, or you had an obligation to perform, provide the
dates of uniformed service in 4a. If your claim is related to a uniformed service branch that you applied to be a
member of, but did not, or have not performed service in, provide the examination or rejection date in 4b.
Questions 5 - 8: Enter all information concerning how your employer was notified of the uniformed service.
Question 9, 10a: Self Explanatory
Questions 10b - 10e: If 10a is "Yes", enter information for 10b through 10d. If 8a is "No", only respond to 10e.

Section D. USERRA Claim Information Instructions

General Instructions: Do not complete this section if your claim involves a potential violation of VP or VEOA.
Questions 1a, 1b: Self Explanatory
Questions 2a - 2i: Read each statement and select "Yes" if that situation applies to your claim. If none of these statements apply to
your claim, contact VETS at [email protected] for assistance.
Questions 3a - 3f: Select each additional USERRA issue you would like VETS to investigate.
Question 3g: Select 3g if your claim involves a health benefits issue covered by USERRA. If 3g is selected, you must also select
the health benefits issue from the drop-down list to the right of 3g.
Questions 3h, 3i: If either of these is selected, provide a description of the benefit of employment to right of the item.

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OMB NO. 1293-0002 (XX/XX/XXXX)
VETS USERRA/VP/VEOA Form 1010(a) (REV XX/XXXX)

Section E. VP/VEOA Eligibility Information Instructions

Do not complete this section if your claim involves a potential violation of USERRA.
Select whether your claim involves a hiring or reduction in force (RIF) issue.
Enter the four digit number of the job series of the position that is the subject of your claim.
Enter the pay schedule for the position that is the subject of your claim. For example, GS, WG, FP, etc.
Self Explanatory
Select from the drop-down list the branch of service related to your claim. This will be the branch of service that
you used to establish your eligibility for veterans preference or eligibility to apply for a position under VEOA.
Question 8: Self Explanatory
Question 9: If "Yes" to 8, select from the drop-down list the Character of Service you received upon discharge or separation.
Question 10: Self Explanatory

General Instructions:
Question 1:
Question 2:
Question 3:
Question 4 - 6:
Question 7:

Section F. VP/VEOA Federal Hiring Claim Information Instructions

General Instructions: Do not complete this section if your claim involves a potential violation of USERRA.
Question 1: Enter the vacancy announcement number from USAJOBS
Question 2: Select "Open Competitive" if the announcement was open to the public, or "Merit Promotion", if the
announcement was not open to the public.
Question 3: Enter the type of preference or eligibility that was used during the application process to entitle you to VP or
VEOA eligibility. For example, TP, XP, CPS, etc.
Questions 4a - 5: Self Explanatory
Question 6: Enter the date that you were first notified, or were made aware of your non-selection.
General Instructions:
Questions 1 - 7:
Question 8:
Question 9:

Section G. RIF Claim Information Instructions

Do not complete this section if your claim involves a potential violation of USERRA.
Enter the values from your most recent SF-50 form.
Enter the date that you were first notified, or were made aware of the Reduction in Force.
Self Explanatory

Section H. USERRA Remedies Instructions

General Instructions: Do not complete this section if your claim involves a potential violation of VP or VEOA.
Questions 1 - 3: Self Explanatory

Section I. Claimant Demographic Information Instructions

General Instructions: Information requested in this section is voluntary, and not required to initiate an investigation.
Question 1: Select yes, if you have a disability for which you are not currently receiving compensation from the Department of
Veterans Affairs.
Questions 2, 3: Self Explanatory
Question 4: Select all races and ethnicities that apply and enter additional details in the spaces below

Section I. USERRA Remedies Instructions

General Instructions: Do not complete this section if your claim involves a potential violation of VP or VEOA.
Questions 1 - 3: Self Explanatory

Section J. Comments/Notes Instructions

Question 1: Self Explanatory

Section O. Certification and Signature Instructions

Signature: Electronic or handwritten signatures will be accepted.
Date: Enter the date that the form is being submitted for processing.

Claim Filing by Mail Instructions

Please be advised that filing a claim by mail will likely delay the processing of your claim. However, VETS accepts and processes claims
filed by mail. To file by mail, you must send your signed, and completed claim form to: Veterans' Employment and Training Service
(VETS), Attention: VETS1010, 200 Constitution Ave NW, Room S-1325, Washington, DC 20210. For assistance filing your claim, please
contact VETS at [email protected].

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